Urethrocutaneous Fistula Following Hypospadias Repair: Recurrence Rate and Its Determinants
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Abstract Background: Urethrocutaneous fistula (UCF) is a common complication following hypospadias repair that may be associated with frequent recurrences after repair and ultimately increases treatment costs and poor cosmetic outcomes due to multiple surgeries. Aim: To evaluate the recurrence rate of post hypospadias urethrocutaneous fistula and its determinants following repair among patients treated at the urology department of Kilimanjaro Christian Medical Centre from January 2011 to December 2023 Methodology: We conducted a hospital-based retrospective study that reviewed case notes of all patients who developed UCF post-hypospadias repair. Patients were followed for at least six months postoperatively and various factors were analyzed to check for their influence on recurrence. Results: The study included 44 patients with urethrocutaneous fistula after hypospadias repair. The recurrence rates after repair were 30% (13 of 44), 30% (4 of 13), 50% (2 of 4), and none in the 1st, 2nd, 3rd, and 4th repairs, respectively. In the bivariate analysis, recurrence was statistically associated with the history of previous proximal hypospadias, distal urethrocutaneous fistula, and multilayer repair technique. However, in the multivariate analysis, only the history of previous proximal hypospadias and distal location of the fistula were significant independent determinants of recurrence (p < 0.005). Conclusion: UCF post hypospadias repair is associated with at least one-third of recurrence following repair. Proximal hypospadias and distal UCF are significantly associated with a high recurrence rate following UCF. Addressing these issues is crucial in developing a strategy to mitigate recurrence and improve surgical outcomes among patients undergoing UC repair. Clinical trial number: Not applicable
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Urethrocutaneous Fistula Following Hypospadias Repair: Recurrence Rate and Its Determinants | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Urethrocutaneous Fistula Following Hypospadias Repair: Recurrence Rate and Its Determinants Nyamhanga Nsaho Maro, Jasper Mbwambo, Orgeness Mbwambo, Frank Bright, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5813275/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Urethrocutaneous fistula (UCF) is a common complication following hypospadias repair that may be associated with frequent recurrences after repair and ultimately increases treatment costs and poor cosmetic outcomes due to multiple surgeries. Aim : To evaluate the recurrence rate of post hypospadias urethrocutaneous fistula and its determinants following repair among patients treated at the urology department of Kilimanjaro Christian Medical Centre from January 2011 to December 2023 Methodology : We conducted a hospital-based retrospective study that reviewed case notes of all patients who developed UCF post-hypospadias repair. Patients were followed for at least six months postoperatively and various factors were analyzed to check for their influence on recurrence. Results : The study included 44 patients with urethrocutaneous fistula after hypospadias repair. The recurrence rates after repair were 30% (13 of 44), 30% (4 of 13), 50% (2 of 4), and none in the 1st, 2nd, 3rd, and 4th repairs, respectively. In the bivariate analysis, recurrence was statistically associated with the history of previous proximal hypospadias, distal urethrocutaneous fistula, and multilayer repair technique. However, in the multivariate analysis, only the history of previous proximal hypospadias and distal location of the fistula were significant independent determinants of recurrence (p < 0.005). Conclusion : UCF post hypospadias repair is associated with at least one-third of recurrence following repair. Proximal hypospadias and distal UCF are significantly associated with a high recurrence rate following UCF. Addressing these issues is crucial in developing a strategy to mitigate recurrence and improve surgical outcomes among patients undergoing UC repair. Clinical trial number : Not applicable Hypospadias Urethrocutaneous fistula Recurrance INTRODUCTION Urethrocutaneous fistula (UCF) is the abnormal connection between the urethral mucosa and the skin, such that the urine stream passes partially or entirely through that opening [ 1 ]. This abnormal opening is usually located on the underside of the penis or perineum. UCF is a common complication of hypospadias repair with a global incidence of 4–47% [ 2 , 3 ]. In Northern Tanzania UCF following hypospadias repair accounts for up to 40.5% of all complications of hypospadias surgery [ 4 ]. The fistula can occur immediately after removal of the urethral catheter/stent or later and can either be single, two, or multiple with variable sizes [ 3 , 5 – 7 ]. Other possible causes of UCF include complicated circumcision, congenital, as a complication of trans-urethral procedures, perineal infection, genital trauma, or malignancy [ 8 – 11 ]. The diagnosis is clinical where assessment of the fistula is better when done intraoperatively. While the size is determined by the use of a caliper, the number of UCF is assessed by retrograde injection of methylene blue solution into the urethra through the external urethral meatus (Son et al., 2020). Management of UCF can either be conservative or surgical repair. Fistula that appears acutely and small following hypospadias repair, can be managed conservatively by replacing the catheter for at least 14 days to allow it to close spontaneously [ 12 – 14 ] Surgical repair options depend on the number, duration, location, size of the fistula and the nature of the surrounding tissues [ 15 ]. The UCF should be at least 6 months old before the repair is done to enable the scar to mature, and also for edema and induration to subside completely [ 16 – 18 ]. In the practical operational workflow, it is essential to assess the presence of meatal stenosis and/or distal urethral strictures during the procedure. If these conditions are identified, appropriate corrective measures should be performed sometime after the stenosis/stricture is released or simultaneously to minimize the risk of fistula recurrence [ 19 ]. Surgical repair for UCF varies from simple closure to multilayer with waterproof flap repair. Simple closure consists of freshening the tissue around the fistulous tract down to the urethral and then tension-free closure of the fistula with a non-overlying suture line. This technique is considered for small, single, and unscarred areas surrounding the fistula; however, it carries a high recurrence rate [ 15 ]. In multilayer repair, the fistula is dissected down to the urethra followed by tension-free closure of the urethral defect. A flap of tissue is then formed from which a vascularized layer is created and placed over the neourethra without tension. Once the urethra is covered, the skin flap is advanced to close the skin defect. There are a variety of tissue flaps that are used to close the fistula, these include penile dartos, scrotal dartos, and tunica vaginalis. Tunica vaginalis is reserved for complex multiple fistulas. Although more complex and time-consuming, the tunica vaginalis flap is more effective and reduces fistula recurrence when used as a second layer [ 20 ]. Although controversies exist on the use of a urethral catheter or stent for urinary diversion after fistula closure, the majority of centers divert the urine [ 21 – 24 ]. The overall recurrence rate of UCF ranges from about 0–28% [ 21 , 25 , 26 ]. Some fistulas may require up to 15 operations for successful closure [ 27 ]. The recurrence of UCF after repair is determined by several factors, including the location, size, technique of fistula closure, and distal obstruction. Additional factors such as patient age and previous repair type may also impact the recurrence rate.[ 27 , 28 ]. UCF continues to present a significant challenge in our setting, affecting both surgeons and patients. This may be attributed to limited surgical expertise, resource constraints, or a high prevalence of complex cases. UCF is frequently associated with recurrence, which prolongs hospital stays, increases treatment costs, and imposes psychological stress due to multiple corrective surgeries [ 17 , 26 ]. Although UCF is recognized as the most common long-term complication following hypospadias repair in Tanzania [ 4 ], data on its recurrence rate and contributing factors remain scarce. This study was conducted to determine the recurrence rate of UCF and identify its key determinants, to inform clinical practice. The findings aim to provide urologists with updated insights that can guide the development of targeted strategies to reduce UCF recurrence and improve surgical outcomes. Methodology Study site, Patients, and methods This retrospective study involved the review of medical records data of all patients who underwent UCF repair from January 2011 to December 2023 following hypospadias repair. The study was conducted at KCMC, a zonal referral hospital located in Kilimanjaro northern Tanzania. The hospital serves 7 regions of the Northern Zone with over 15 million people [29]. As a consultant hospital in the northern zone, KCMC has a well-established institute of urology that serves patients referred from regions within and outside its catchment area. The institute serves as a referral, training, and research center for all urological conditions. It performs an average of one hypospadias repair each month and one UCF repair every two months. All surgeries are done by a urologist or resident under the guidance of a specialist. Data collection process and analysis: The registration numbers of all patients who underwent UCF repair during the study period were obtained from the theatre register books of the urology department of KCMC. Thereafter patients’ information was retrieved from physical files obtained from the department of medical record. The retrieved patient information was collected using a structured data extraction sheet and included Age, type of hypospadias, the interval between hypospadias repair to UCF repair, techniques used for fistula repair, duration of catheter/stent, suture material, and size and whether the fistula recurred and number of recurrences. The study included all patients with UCF due to hypospadias and repaired during a study period and excluded all patients with other causes of fistula formation such as circumcision, urethral stricture, epispadias, and those who were not followed up for at least six months. Data were entered into IBM Statistical Package for Social Science (SPSS) version 25, cleaned, analyzed, and summarized. Descriptive statistics were used to summarize data whereby measures of central tendencies and their respective dispersions were used to summarize continuous variables. Proportions and percentages were used to summarize categorical variables. Modified poison was used to analyze data, Crude and adjusted regression and risk ratio (risk ratio) with their 95% confidence intervals were used to check for determinants associated with UCF recurrence after the first repair. A P-value of less than 0.05 was considered statistically significant. Ethics The College Research Ethics Review Committee (CRERC) of the Kilimanjaro Christian Medical University College (KCMUCo) approved the study (No. PG 98/2023 ). No patients’ identifiers were used, instead patients’ ID numbers were used and all information was kept confidential. RESULTS During the study period, a total of 113 patients underwent UCF repair. However, 43(38%) patients could not be retrieved and hence excluded from the analysis. Of the remaining 70 (62%) patients whose files were retrievable, 26 were excluded (36.2 %) as their UCF resulted from other causes such as circumcision, urethral stricture, urethral trauma, and epispadias repair. The remaining 44(62.8%) patients who underwent UCF repair post hypospadias repair and who completed at least six months of post-operative follow-up were included in the final analysis. Characteristics of study participants The median age of patients at first fistula surgery was 4 years with the majority 29(65.9%) being under 5 years. Most of the UCF 39(92.8%) were located at the distal penile and 13(30%) patients needed more than one repair to close the fistula tract. The majority of cases (43.2%) had UCF repair more than 12 months after hypospadias repair, while 34.1% had it within 7-12 months, and 22.7% had it within 6 months with a median time of 14 months. Multilayer repair using the penile dartos and tunica vaginalis flaps were the common technique of UCF closure in 38(86.4%) of cases. Urethral catheter/stent was used on all patients with a median of 12 days (range 7-25 days). (Table 1). Table 1: Demography and background characteristics of study participants Variable n Percentage (%) Age £5years 29 65.9 >5years 15 34.1 Median(range) 4(3.0-6.5) Area of residency Arusha 15 34.1 Kilimanjaro 19 43.2 Other regions* 10 22.7 Location of EUM at hypospadias repair, n=37 Distal penile 21 56.8 Mid/Proximal 16 43.2 Location of UCF, n=42 Distal penile 39 92.9 Mid/Proximal 3 7.1 Technique of hypospadias repair TIP 26 59.1 Two-stage repairs 13 29.5 Other techniques** 5 11.4 Time from hypospadias repair to UCF repair £6 months 10 22.7 7-12months 15 34.1 >12 months 19 43.2 Median(range) 14(13.5-30) Duration of urethral catheter/stent £7 days 12 27.3 >7 days 32 72.7 Median(range) 12(7.5-25) Technique used for 1st UCF repair Multilayer repair 38 86.4 Simple 2 4.6 Other techniques*** 4 9 Suture material Vicryl 33 75 Monocryl 6 13.6 Biosyn/PDS 5 11.4 Suture size size 4-0 7 15.9 size 5-0 21 47.7 size 6-0 16 36.4 *Other regions- Morogoro (3), Mwanza (2), Tabora (2), Mbeya 1, Kigoma (1), Tanga (1). **Other techniques for hypospadias repair – Duckett repair 2, Mathieu repair 3 ***Other technique for UCF repair – Coronal fistula converted to coronal hypospadias and repaired (4). EUM-External urethra meatus; PDS-Polydioxanone suture TIP- Tubularized incised plate; UCF-Urethrocutaneous fistula Recurrence rate of Urethrocutaneous Fistula Among the 44 patients who underwent UCF repair, recurrence occurred 30% after the first attempt. Subsequent repairs showed recurrence rates of 30% for the second repair and 50% for the third, while no recurrences occurred after the fourth repair. Recurrence was more frequent in younger children (≤5 years) 37.9% (11 of 29), mid/proximal hypospadias 56.2%(9 of 16), longer catheter duration (>7 days) 34.3%(11 of 32), multilayer closure 34.2%(13 of 38), and use of 5/0 suture size 33.3%(7 of 21). However, on univariate analysis, only the type of hypospadias (p=0.007) and location of the fistula (p=0.027) were statistically significant predictors of recurrence. Other factors including age, hypospadias repair technique, catheter duration, and suture type or size did not show significant associations. Table 2: Characteristics of determinants of UCF recurrence after repair Variable UCF Recurrence Total, n(%) Yes, n(%) No, n(%) p-Value Age 0.09 £ 5 years 29 (65.9) 11 (84.6) 18 (58.1) >5years 15 (34.1) 2 (15.4) 13 (41.9) Location of EUM at hypospadias repair, n=37 0.007 Distal penile 21 (56.8) 3 (25.0) 18 (72.0) Mid/proximal penile 16 (43.2) 9 (75.0) 7 (28.0) Location of UCF n=42 0.027 Mid/proximal penile 3 (7.1) 0 3 (10) Distal penile 39 (92.9) 12 (100) 27 (90) Technique of hypospadias repair 0.118 Other technique* 31(70.45%) 7(53.8) 24(77.42%) Two-stage repairs 13(29.55%) 6(46.2) 7(22.58%) Time from hypospadias repair to UCF repair 0.905 ≤6 months 10 (22.7) 3 (23.1) 7 (22.6) 7–12 months 15 (34.1) 5 (38.4) 10 (32.3) >12 months 19 (43.2) 5 (38.5) 14 (45.1) Duration of urethral catheter/stent 0.252 £ 7 days 12 (27.3) 2 (15.4) 10 (32.3) >7 days 32 (72.7) 11 (84.6) 21 (67.7) Technique used for 1 st UCF repair 0.233 Multilayer repair 38 (86.4) 13 (100.) 25 (80.7) Simple repair 2 (4.5) 0 2 (6.4) Other techniques** 4 (9.1) 0 4 (12.9) Suture material 0.63 Monocryl 6 (13.6) 1 (7.7) 5 (16.1) Biosyn/PDS 5 (11.4) 1 (7.7) 4 (12.9) Vicryl 33 (75.0) 11 (84.6) 22 (71.0) Suture size 0.441 size 4/0 7 (15.9) 3 (23.1) 4 (12.9) size 5/0 21 (47.7) 7 (53.8) 14 (45.2) size 6/0 16 (36.4) 3 (23.1) 13 (41.9) *Other techniques for hypospadias repair – TIP (26), Duckett repair (2), Mathieu repair (3), **Other technique for UCF repair - coronal fistula converted to coronal hypospadias and repaired (4). EUM-External urethra meatus; PDS-Polydioxanone suture TIP- Tubularized incised plate; UCF-Urethrocutaneous fistula Determinants of recurrence of UCF after repair By bivariate analysis, distal penile fistula and proximal hypospadias had a significantly higher risk of recurrent fistula [RR; 1.23, 95% CI(1.17-4.51), p =0.027] and [RR; 7.71, 95% CI1(1.6-37.13), p =0.011] respectively as compared to their counterparts. Age, previous technique of hypospadias repair, time from hypospadias repair to UCF repair, suture material, and suture size were not significantly associated with UCF recurrence (p> 0.05) In multivariate regression analysis, after adjusting all variables in the model, still, patients who had distal urethracutaneous fistula had a statistically significant higher risk of fistular recurrence after repair. [Adjusted RR;1.73, 95% CI(1.53-2.20), p = 0.048]. Patients who had distal penile hypospadias had a significantly lower risk for recurrence [Adjusted RR; 4.21, 95% CI(1.31-17.20), p =0.029] as compared to their counterparts with mid/proximal penile hypospadias ( Table 3). Table 3: Multivariate analysis on determinants of UCF recurrence after repair CRUDE ADJUSTED RR(95% CI) p-Value RR(95% CI) p-Value Age £5years 1 1 >5years 0.25(0.04-1.33) 0.105 0.20 (0.01–2.88) 0.236 Location of UCF, n=42 Mid/proximal penile 1 1 Distal Penile 1.23(1.17-4.51) 0.027 1.73(1.53-3.20) 0.048 Location of EUM at Hypospadias repair 1 Distal 1 1 Mid/Proximal 7.71(1.6-37.13) 0.011 4.21(1.31-17.20) 0.029 Technique hypospadias repair *Other techniques 1 Two-stage repairs 0.34(0.08-1.34) 0.125 1.71 (0.10–30.16) 0.715 Time for Hypospadias repair to UCF repair ≤6 months 1 1 7–12 months 1.16(0.20-6.55) 0.861 4.75 (0.20–11.90) 0.334 >12 months 0.83(0.15-4.53) 0.833 3.73 (0.25–15.75) 0.34 Duration catheter after UCF repair £7 days 1 1 >7 days 2.61(0.48-14.11) 0.263 5.70 (0.25–13.27) 0.277 Technique used for 1st UCF repair **Other techniques 1 1 Multilayer repair 6.88(0.35-13.64) 0.2 13.04 (0.24–71.34) 0.209 Suture Material Used for UCF Repair Monocryl 1 1 Biosyn/PDS 1.25(0.05-26.86) 0.887 10.20 (0.05–18.65) 0.384 Vicryl 2.5(0.25-24.09) 0.428 4.93 (0.21–11.56) 0.325 Suture size used for UCF repair size 4-0 1 1 size 5-0 0.66(0.12-3.83) 0.65 1.08 (0.04–28.06) 0.963 size 6-0 0.30(0.04-2.17) 0.237 0.15 (0.00–6.41) 0.326 P-value, RR-Relative risk, CI-Confidence Interval, adjusted run for all independent variable *Other techniques for hypospadias repair – TIP, Duckett repair, Mathieu repair **Other technique for UCF repair - Simple repair, coronal fistula converted to coronal hypospadias and repaired. EUM-External urethra meatus; PDS-Polydioxanone suture, TIP- Tubularized incised plate; UCF-Urethrocutaneous fistula Discussion Management of urethrocutaneous fistulas (UCF) after hypospadias repair remains a significant problem, with studies indicating variable recurrence rates ranging from 0% to 28%, [21,25,26] influenced by different factors. This study, being the first of its kind in Tanzania, reported an overall recurrence rate of 30%, with 13 out of 44 patients experiencing recurrence after the first repair, and subsequently, 4 out of those 13 having recurrence after the second repair. The findings align with a study conducted in the USA, which documented recurrence rates of 28% after the first repair and 33% after the second [30]. A noteworthy observation from this study is that prior UCF repair did not seem to impact the recurrence rates of subsequent repairs, which is consistence with previous published reports [21,31]. Conversely, several prior studies have reported lower recurrence rates. For instance, a study noted a 6% recurrence rate (2/32) after a tunica vaginalis flap (TVF) repair [6], and another study highlighted a 13% recurrence rate (2/15) following the Preserve the Tract and Turn it Inside Out (PATIO) repair method [32]. Low recurrence rates in these studies may be attributed to the surgeon’s familiarity with a single surgical technique which increases standardization and consistency. However, this discrepancy in recurrence rates emphasizes the need for further research to identify the determinants influencing UCF recurrence in various populations and surgical techniques. In this index study, the recurrence of UCF after repair was significantly associated with a previous history of proximal hypospadias and distal fistula location. Patients with previous history of proximal hypospadias have a higher risk of fistula recurrence which may be due to the complex tissue mobilization required for neo-meatus placement at the tip. Staged repairs which are done for most proximal hypospadias can compromise surrounding tissues needed for subsequent fistula repair[21]. Another study identified the type of hypospadias as an independent risk factor for failed UCF repair, with penoscrotal hypospadias having a higher rate of failure of UCF repair [28]. A similar study has shown that distal fistulas are associated with a higher recurrence rate compared to proximal ones [14]. This may be due to the fragility of the distal penile skin, compromised blood supply from previous surgeries, and traction at the coronal sulcus—particularly during erections in the early postoperative period. Moreover, this anatomical region lacks sufficient tissue for a second-layer closure, further complicating repair efforts [24]. The use of simple repair techniques at this site has also been linked to increased recurrence. Hence distal UCFs, especially those located at the coronal sulcus, are particularly challenging to manage. Previous studies recommend avoiding simple repair techniques in these cases and instead advocate for the use of advancement or rotational flaps to improve surgical outcomes [14]. However, when the distal fistula is large, it is better to connect it to the distal meatus and convert it to hypospadias and be repaired by tubularization of the urethral plate and multilayer coverage with healthy tissues [27]. In our study, four coronal UCFs were converted to coronal hypospadias and repaired without recurrence. Success in repairing proximal fistulas may be attributed to the meticulous surgical techniques employed and the careful selection of well-vascularized flaps. For instance, two cases of proximal UCF were successfully repaired using the tunica vaginalis flap, which provides robust vascular support. Additionally, the low recurrence rate in this group might also be influenced by the relatively small number of patients. Other studies have shown no significant difference in recurrence among distal and proximal UCF [17,33–35]. Various techniques for correcting UCF have been studied, demonstrating variable success rates influenced by factors such as the number, size, location of the fistula, and the nature of surrounding tissues [36][26][37][7][16][38]. Multilayer repair utilizing flaps, such as penile dartos or tunica vaginalis, and grafts like buccal mucosa or synthetic materials, is effective with a low recurrence rate. In our study, the majority of fistulas were repaired using multilayer repair with penile dartos as an intermediate layer—a straightforward technique. Urethral calibration was often performed to assess for strictures or meatal stenosis before proceeding with repairs. If a stricture was identified during calibration, it was typically repaired first to ensure proper functionality of the urethra before UCF repair While most previous studies indicate that the multilayer closure method typically has a low recurrence rate [26,39], our findings showed a higher recurrence rate in multilayer repairs compared to other techniques; however, this difference was not statistically significant. This observation may be attributed to the use of poorly vascularized flaps with flap necrosis, scar tissues, and the limited number of patients repaired using alternative techniques. Various other techniques such as PATIO, Multilayer Direct Closure With a Longitudinal Relaxing Incision, the use of buccal mucosa, and synthetic graft have shown promising results with success in UCF repair, these highlight the need for more standardized and individualized approaches in UCF repair[25,32,38,40] The history of previous hypospadias surgeries may impact the recurrence of UCF, as extensive procedures involving significant tissue mobilization can compromise the blood supply to the periurethral area, affecting subsequent UCF repairs. Waterman et al. demonstrated that the King and Yoke technique resulted in lower fistula recurrence, likely due to reduced tissue mobilization and preserved ventral blood supply [21]. In our study, while the tubularized incised plate (TIP) technique was predominantly utilized compared to staged repair, Mathieu, and Duckett techniques, variations in these surgical approaches did not significantly influence UCF recurrence. UCF repair is generally recommended at least 6 months after the primary hypospadias surgery to allow for proper healing, reduced scarring, and improved skin vascularization around the fistula site as reported by previously published data [26,41]. In this study: The median time from initial surgery to UCF repair was 14 months, 10 patients (22.7%) had repairs done within six months. One case repaired at two months recurred. Repairs at 4 and 5 months did not recur. No statistically significant difference in recurrence was found between those repaired before or after 6 months. This aligns with findings by Watermal et al, who also saw no significant difference in success rates between early (3.7–6 months) and later repairs (≥6 months) [21]. While our data doesn’t show a significant statistical difference, waiting at least 6 months remains the preferred approach to optimize outcomes. In the current study, the type of suture material did not significantly impact the UCF recurrence after repair, this aligns with the study done by Wahyudi et al which found no significant difference in complication rates between absorbable synthetic braided and monofilament during urethra surgery [42]. Furthermore, the suture material showed no significant impact on UCF recurrence possibly because other factors like suturing technique, tissue handling, and tissue health play a more crucial role in fistula closure. The use of a catheter/stent during UCF repair is a topic of debate. Despite varying durations of catheter/stent ranging from 1 to 30 days in all UCF repairs in this study, there was no significant difference in recurrence among the different groups. Waterman et al concluded in their study that there was no clear difference in recurrence between using a stent versus not using a stent during UCF repair [21]. On the other hand, Dekalo et al did not view the use of a catheter/stent as a preferable option for UCF repair [34]. We used a urethral catheter/stent for all our patients undergoing UCF repair because we believed that it prevents urine extravasation to the surgical site, prevents post-operative dysuria, and supports urethral healing. Strength and Limitation This is the first study to report the recurrence rate of UCF after repair in Tanzania it also highlighted the key determinants that influence the recurrence of UCF after repair. Although the findings of this study are comparable to many other similar studies, these findings should be discussed in light of the following limitations; Firstly, the retrospective nature of the study which led to missing patients’ files and some variables and hence ended up with the small sample size, that might have caused overestimation of the proportions. Inconsistent documentation led to missing important variables for analysis such as surgeon experience, intraoperative tissue handling, number and size of fistula, suturing technique, and many others which may impact UCF repair. Secondly, the study was conducted in a single center which limits the generalizability of the findings to a broader population. However, the findings can be generalized to a setting with a similar context. Conclusions and Recommendation UCF following hypospadias repair is associated with frequency recurrence. In this study, the recurrence rate of UCF after the repair is 30% (13 of 44), 30% (4 of 13), 50% (2 of 4), and none in the 1 st , 2 nd , 3 rd, and 4 th repair respectively. Recurrence of UCF after surgical repair is significantly influenced by history of proximal hypospadias and having distal UCF. Hence before attempting to repair, thorough patient evaluation should be done. Addressing these issues is crucial in developing a strategy to mitigate recurrence and improve surgical outcomes among patients undergoing UCF repair. Furthermore, all confounding factors cannot completely be excluded, a further prospective study with a large number sample size should be conducted to validate these findings and explore additional factors influencing UCF recurrence Declarations Acknowledgments: The administration of Kilimanjaro Christian Medical Center allows the use of the hospital medical records, the Kilimanjaro Christian Medical University College for providing ethical clearance, and all staff from the Urology department. Conflict of interest: Authors have no conflict of interest. Authors' contributions Nyamhanga Nsaho Maro: Writing – original draft. Frank Bright : Writing – review and editing. Orgeness Mbwambo : Writing – review and editing. Jaspar Mbwambo : Writing- review and editing. Bartholomeo Nicholaus Ngowi : Supervision; writing – original draft. Funding: There was no funding for this research Availability of data materials : The dataset used during the present study is available from the corresponding author upon reasonable request. Ethical approval and consent to participate: Ethical approval number PG 98/2023 was obtained from Kilimanjaro Christian Medical University College Research and Ethical Review Committee. All enrolled patients gave written general informed consent for the future use of data/materials for research; in the case of patients younger than 18 years, consents were signed by both the patient and one of their parents. Consent for publication : Not Applicable. Patient identity did not appear in any part of the manuscript; therefore, consent for publication was not required. References Lucas T, Hines JZ, Samuelson J, Hargreave T, Davis SM, Fellows I, et al. Urethrocutaneous fistulas after voluntary medical male circumcision for HIV prevention—15 African Countries, 2015–2019. 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Bhat S, Nair C, Shetty S, Paul F. Tunica Vaginalis Flap Repair for Urethrocutaneous Fistulae. J Clin Diagnostic Res 2019;13:2017–9. https://doi.org/10.7860/jcdr/2019/42702.13364. Jamal YS, Kurdi MO, Moshref SS. Management of Small Urethrocutaneous Fistula by Tight Ligation with Fulguration of the External Epithelium of the Tract 2010;6:150–3. Obi AO. Traumatic urethrocutaneous fistula: Case report and literature review. African J Urol 2013;19:198–201. https://doi.org/10.1016/j.afju.2013.07.002. Bhari N, Jangid BL, Singh S, Mittal S, Ali F, Yadav S. Urethrocutaneous fistula: a rare presentation of penile tuberculosis. Int J STD AIDS 2017;28:97–9. https://doi.org/10.1177/0956462416647624. Galinier P, Mouttalib S, Carfagna L, Vaysse P, Moscovici J. Congenital anterior urethrocutaneous fistula associated with a stenosis of the bulbar urethra in the context of high anorectal malformation without fistula. J Plast Reconstr Aesthetic Surg 2009;62. https://doi.org/10.1016/j.bjps.2008.04.050. 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A simple method for closure of urethrocutaneous fistula after tubularized incised plate repair: Preliminary results. Nephrourol Mon 2016;8. https://doi.org/10.5812/numonthly.40371. Landau EH, Gofrit ON, Meretyk S, Katz G, Golijanin D, Shenfeld OZ, et al. Outcome analysis of tunica vaginalis flap for the correction of recurrent urethrocutaneous fistula in children. J. Urol., vol. 170, Lippincott Williams and Wilkins; 2003, p. 1596–9. https://doi.org/10.1097/01.ju.0000084661.05347.58. Srivastava RK, Tandale MS, Panse N, Gupta A, Sahane P. Management of urethrocutaneous fistula after hypospadias surgery - An experience of thirty-five cases. Indian J Plast Surg 2011;44:98–103. https://doi.org/10.4103/0970-0358.81456. Yassin T, Bahaaeldin KH, Husein A, El Minawi H. Assessment and management of urethrocutaneous fistula developing after hypospadias repair. Ann Pediatr Surg 2011;7:88–93. https://doi.org/10.1097/01.XPS.0000397066.98404.82. Ochi T, Seo S, Yazaki Y, Okawada M, Doi T, Miyano G, et al. Traction-assisted dissection with soft tissue coverage is effective for repairing recurrent urethrocutaneous fistula following hypospadias surgery. Pediatr Surg Int 2015;31:203–7. https://doi.org/10.1007/s00383-014-3652-1. Pescheloche P, Parmentier B, Hor T, Chamond O, Chabaud M, Irtan S, et al. Tunica vaginalis flap for urethrocutaneous fistula repair after proximal and mid-shaft hypospadias surgery: A 12-year experience. J Pediatr Urol 2018;14:421.e1-421.e6. https://doi.org/10.1016/j.jpurol.2018.03.026. Waterman BJ, Renschler T, Cartwright PC, Snow BW, DeVries CR. Variables in successful repair of urethrocutaneous fistula after hypospadias surgery. J Urol 2002;168:726–30. https://doi.org/10.1016/s0022-5347(05)64734-9. Shehata SM. Use of the TIP principle for the repair of non-glanular recurrent post hypospadias urethrocutaneous mega fistula. Eur J Pediatr Surg 2009;19:395–8. https://doi.org/10.1055/s-0029-1243170. Aldaqadossi HA, Eladawy M, Shaker H, Kotb Y, Azazy S. Tunica vaginalis graft for recurrent urethrocutaneous fistula repair after hypospadias surgery. Int J Urol 2020;27:726–30. https://doi.org/10.1111/iju.14287. Snyder CL, Evangelidis A, Hansen G, St. Peter SD, Ostlie DJ, Gatti JM, et al. Management of complications after hypospadias repair. Urology 2005;65:782–5. https://doi.org/10.1016/j.urology.2004.11.037. 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;84:317–21. https://doi.org/10.1097/SAP.0000000000002056. Biswas A, Kmd I, Chaki A, Akmk B, Mz H. Original Article Result of simple versus layered repair of urethro-cutaneous fistula developing after hypospadias surgery. J Paediatr Surg Bangladesh 2019;10:37–42. Richter F, Pinto PA, Stock JA, Hanna MK. Management of recurrent urethral fistulas after hypospadias repair. Urology 2003;61:448–51. https://doi.org/10.1016/S0090-4295(02)02146-5. Abdullaev Z, Agzamkhodjaev S, Chung JM, Lee SD. Risk factors for fistula recurrence after urethrocutaneous fistulectomy in children with hypospadias. Turkish J Urol 2021;47:237–41. https://doi.org/10.5152/tud.2020.20323. Mremi A, Mswima J, Mlay MG, Bartholomew H, Julius P, Mmbaga BT, et al. experience in Tanzania 2023. https://doi.org/10.1016/j.ctarc.2020.100213.Cancer. Holland AJA, Abubacker M, Smith GHH, Cass DT. Management of urethrocutaneous fistula following hypospadias repair. Pediatr Surg Int 2008;24:1047–51. https://doi.org/10.1007/s00383-008-2202-0. Sunay M, Dadali M, Karabulut A, Emir L, Erol D. Our 23-Year Experience in Urethrocutaneous Fistulas Developing After Hypospadias Surgery. Urology 2007;69:366–8. https://doi.org/10.1016/j.urology.2006.12.012. 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;33:109–12. https://doi.org/10.1007/s00383-016-3983-1. Feng J, Yang Z, Tang Y, Chen W, Zhao MX, Ma N, et al. Risk Factors for Urethrocutaneous Fistula Repair after Hypospadias Surgery: A Retrospective Study. Ann Plast Surg 2017;79:e41–4. https://doi.org/10.1097/SAP.0000000000001128. Dekalo S, Ben-David R, Bar-Yaakov N, Dubi-Sobol A, Ekstein M, Ben-Chaim J, et al. In Support of a Simple Urethrocutaneous Fistula Closure Technique Following Hypospadias Repair. Urology 2020;143:212–5. https://doi.org/10.1016/j.urology.2020.06.015. Malhotra NR, Schaeffer AJ, Slade AD, Cartwright PC, Lau GA. Post-hypospadias urethrocutaneous fistulae: no difference in repair success between proximal and distal fistulae. Can J Urol 2020;27:10466–70. Singh A, Shukla A, Sharma P, Barolia D. A simple procedure for management of urethrocutaneous fistula after hypospadias repair. Menoufia Med J 2019;32:1223. https://doi.org/10.4103/mmj.mmj_213_18. Shaw NM, Mallahan C, Joshi P, Venkatesan K, Kulkarni S. Novel use of Asopa technique for penile urethrocutaneous fistula repair. Int Urol Nephrol 2021;53:1127–33. https://doi.org/10.1007/s11255-020-02767-6. Tawfeek AM, Mohareb AM, Higazy A, Farouk A, Elsaeed KO, Tawfick A, et al. Isoamyl 2-cyanoacrylate interposition in the urethro-cutaneous fistula repair: A randomized controlled trial. African J Urol 2021;27. https://doi.org/10.1186/s12301-021-00197-z. Cimador M, Castagnetti M, De Grazia E. Urethrocutaneous fistula repair after hypospadias surgery. BJU Int 2003;92:621–3. https://doi.org/10.1046/j.1464-410X.2003.04437.x. Hosseini J, Kaviani A, Mohammadhosseini M, Rezaei A, Rezaei I, Javanmard B. Fistula repair after hypospadias surgery using a buccal mucosal graft. Urol J 2009;6:19–22. Han W, Zhang W, Sun N. Risk factors for failed urethrocutaneous fistula repair after transverse preputial island flap urethroplasty in pediatric hypospadias. Int Urol Nephrol 2018;50:191–5. https://doi.org/10.1007/s11255-017-1773-x. Wahyudi I, Angga P, Raharja R, Situmorang GR, Rodjani A. Journal of Pediatric Surgery Open Associations between suturing techniques and suture materials with complications of tubularised incised plate urethroplasty : A systematic review and meta-analysis 2023;1. https://doi.org/10.1016/j.yjpso.2023.100003. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5813275","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":445939416,"identity":"72513fc0-5811-46e0-aa5f-1d85a0425bb8","order_by":0,"name":"Nyamhanga Nsaho Maro","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0ElEQVRIiWNgGAWjYBCDBAb2BgZmErXwHCBZi0QCkVrMJZKfbi74Y5fHL/nG8HNBhQ0Df3t3Al4tljPSzG7PbEsulpydYyw940wag8SZsxvwajG4kWB2m7eBOXHD7RwDad62wwwGErmEtKR/u83zpz5xw80zxr+J1JJjdpuH7XDihhs8ZkTacuZN2W3etuOJM3vSyqx5zqTxEPbL8fRtQIdVJ/azH958m6fCRo6/vRe/FgaBBBiLwwBE8uBXDgL8B2As9geEVY+CUTAKRsGIBACOIknimLyp/AAAAABJRU5ErkJggg==","orcid":"","institution":"Kilimanjaro Christian Medical University College","correspondingAuthor":true,"prefix":"","firstName":"Nyamhanga","middleName":"Nsaho","lastName":"Maro","suffix":""},{"id":445939417,"identity":"914394af-2b35-4499-a7a3-2033c5c63808","order_by":1,"name":"Jasper Mbwambo","email":"","orcid":"","institution":"Kilimanjaro Christian Medical University College","correspondingAuthor":false,"prefix":"","firstName":"Jasper","middleName":"","lastName":"Mbwambo","suffix":""},{"id":445939418,"identity":"feb6a501-c375-4827-8cc7-334e716e002c","order_by":2,"name":"Orgeness Mbwambo","email":"","orcid":"","institution":"Kilimanjaro Christian Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Orgeness","middleName":"","lastName":"Mbwambo","suffix":""},{"id":445939419,"identity":"a79bc542-6f2f-49f2-a09a-911c2f7b742b","order_by":3,"name":"Frank Bright","email":"","orcid":"","institution":"Kilimanjaro Christian Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Frank","middleName":"","lastName":"Bright","suffix":""},{"id":445939420,"identity":"e200b9d0-c8d4-4f1c-98f3-29851812c091","order_by":4,"name":"Bartholomeo Nicholaus Ngowi","email":"","orcid":"","institution":"Kilimanjaro Christian Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Bartholomeo","middleName":"Nicholaus","lastName":"Ngowi","suffix":""}],"badges":[],"createdAt":"2025-01-12 11:08:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5813275/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5813275/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83942007,"identity":"4cc5614e-f760-4aea-b9bb-dfb52a65f91e","added_by":"auto","created_at":"2025-06-04 18:46:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1175715,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5813275/v1/9deb5820-b240-4330-9662-b935a804ce6a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eUrethrocutaneous Fistula Following Hypospadias Repair: Recurrence Rate and Its Determinants\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eUrethrocutaneous fistula (UCF) is the abnormal connection between the urethral mucosa and the skin, such that the urine stream passes partially or entirely through that opening [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This abnormal opening is usually located on the underside of the penis or perineum.\u003c/p\u003e \u003cp\u003eUCF is a common complication of hypospadias repair with a global incidence of 4\u0026ndash;47% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In Northern Tanzania UCF following hypospadias repair accounts for up to 40.5% of all complications of hypospadias surgery [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The fistula can occur immediately after removal of the urethral catheter/stent or later and can either be single, two, or multiple with variable sizes [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Other possible causes of UCF include complicated circumcision, congenital, as a complication of trans-urethral procedures, perineal infection, genital trauma, or malignancy [\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The diagnosis is clinical where assessment of the fistula is better when done intraoperatively. While the size is determined by the use of a caliper, the number of UCF is assessed by retrograde injection of methylene blue solution into the urethra through the external urethral meatus (Son et al., 2020).\u003c/p\u003e \u003cp\u003eManagement of UCF can either be conservative or surgical repair. Fistula that appears acutely and small following hypospadias repair, can be managed conservatively by replacing the catheter for at least 14 days to allow it to close spontaneously [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] Surgical repair options depend on the number, duration, location, size of the fistula and the nature of the surrounding tissues [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe UCF should be at least 6 months old before the repair is done to enable the scar to mature, and also for edema and induration to subside completely [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In the practical operational workflow, it is essential to assess the presence of meatal stenosis and/or distal urethral strictures during the procedure. If these conditions are identified, appropriate corrective measures should be performed sometime after the stenosis/stricture is released or simultaneously to minimize the risk of fistula recurrence [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSurgical repair for UCF varies from simple closure to multilayer with waterproof flap repair. Simple closure consists of freshening the tissue around the fistulous tract down to the urethral and then tension-free closure of the fistula with a non-overlying suture line. This technique is considered for small, single, and unscarred areas surrounding the fistula; however, it carries a high recurrence rate [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn multilayer repair, the fistula is dissected down to the urethra followed by tension-free closure of the urethral defect. A flap of tissue is then formed from which a vascularized layer is created and placed over the neourethra without tension. Once the urethra is covered, the skin flap is advanced to close the skin defect. There are a variety of tissue flaps that are used to close the fistula, these include penile dartos, scrotal dartos, and tunica vaginalis. Tunica vaginalis is reserved for complex multiple fistulas. Although more complex and time-consuming, the tunica vaginalis flap is more effective and reduces fistula recurrence when used as a second layer [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough controversies exist on the use of a urethral catheter or stent for urinary diversion after fistula closure, the majority of centers divert the urine [\u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The overall recurrence rate of UCF ranges from about 0\u0026ndash;28% [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Some fistulas may require up to 15 operations for successful closure [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The recurrence of UCF after repair is determined by several factors, including the location, size, technique of fistula closure, and distal obstruction. Additional factors such as patient age and previous repair type may also impact the recurrence rate.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUCF continues to present a significant challenge in our setting, affecting both surgeons and patients. This may be attributed to limited surgical expertise, resource constraints, or a high prevalence of complex cases. UCF is frequently associated with recurrence, which prolongs hospital stays, increases treatment costs, and imposes psychological stress due to multiple corrective surgeries [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Although UCF is recognized as the most common long-term complication following hypospadias repair in Tanzania [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], data on its recurrence rate and contributing factors remain scarce. This study was conducted to determine the recurrence rate of UCF and identify its key determinants, to inform clinical practice. The findings aim to provide urologists with updated insights that can guide the development of targeted strategies to reduce UCF recurrence and improve surgical outcomes.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003e\u003cstrong\u003eStudy site, Patients, and methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective study involved the review of medical records data of all patients who underwent UCF repair from January 2011 to December 2023 following hypospadias repair.\u0026nbsp;The study was conducted at KCMC, a zonal referral hospital located in Kilimanjaro northern Tanzania. The hospital serves 7 regions of the Northern Zone with over 15 million people [29].\u003c/p\u003e\n\u003cp\u003eAs a consultant hospital in the northern zone, KCMC has a well-established institute of urology that serves patients referred from regions within and outside its catchment area. The institute serves as a referral, training, and research center for all urological conditions. It performs an average of one hypospadias repair each month and one UCF repair every two months. All surgeries are done by a urologist or resident under the guidance of a specialist.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection process and analysis:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe registration numbers of all patients who underwent UCF repair during the study period were obtained from the theatre register books of the urology department of KCMC. Thereafter patients\u0026rsquo; information was retrieved from physical files obtained from the department of medical record. The retrieved patient information was collected using a structured data extraction sheet and included Age, type of hypospadias, the interval between hypospadias repair to UCF repair, techniques used for fistula repair, duration of catheter/stent, suture material, and size and whether the fistula recurred and number of recurrences.\u0026nbsp;The study included all patients with UCF due to hypospadias and repaired during a study period and excluded all patients with other causes of fistula formation such as circumcision, urethral stricture, epispadias, and those who were not followed up for at least six months.\u003c/p\u003e\n\u003cp\u003eData were entered into IBM Statistical Package for Social Science (SPSS) version 25, cleaned, analyzed, and summarized. Descriptive statistics were used to summarize data whereby measures of central tendencies and their respective dispersions were used to summarize continuous variables. Proportions and percentages were used to summarize categorical variables. \u0026nbsp;Modified poison was used to analyze data, Crude and adjusted regression and risk ratio (risk ratio) with their 95% confidence intervals were used to check for determinants associated with UCF recurrence after the first repair. A P-value of less than 0.05 was considered statistically significant.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe College Research Ethics Review Committee (CRERC) of the Kilimanjaro Christian Medical University College (KCMUCo) approved the study (No.\u0026nbsp;\u003cstrong\u003ePG 98/2023\u003c/strong\u003e). No patients\u0026rsquo; identifiers were used, instead patients\u0026rsquo; ID numbers were used and all information was kept confidential.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eDuring the study period, a total of 113 patients underwent UCF repair. However, 43(38%) patients could not be retrieved and hence excluded from the analysis. Of the remaining 70 (62%) patients whose files were retrievable, 26 were excluded (36.2 %) as their UCF resulted from other causes such as circumcision, urethral stricture, urethral trauma, and epispadias repair.\u0026nbsp;The remaining 44(62.8%) patients who underwent UCF repair post hypospadias repair and who completed at least six months of post-operative follow-up were included in the final analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCharacteristics of study participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe median age of patients at first fistula surgery was 4 years with the majority 29(65.9%) being under 5 years. Most of the UCF 39(92.8%) were located at the distal penile and 13(30%) patients needed more than one repair to close the fistula tract. The majority of cases (43.2%) had UCF repair more than 12 months after hypospadias repair, while 34.1% had it within 7-12 months, and 22.7% had it within 6 months with a median time of 14 months.\u0026nbsp;Multilayer repair using the penile dartos and tunica vaginalis flaps were the common technique of UCF closure in 38(86.4%) of cases. Urethral catheter/stent was used on all patients with a median of 12 days (range 7-25 days). (Table 1).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp id=\"_Toc171607142\"\u003eTable 1: Demography and background characteristics of study participants\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"580\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003e\u0026pound;5years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e65.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003e\u0026gt;5years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e34.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003eMedian(range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4(3.0-6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eArea of residency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003eArusha\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e34.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003eKilimanjaro\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e43.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003eOther regions*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e22.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocation of EUM at hypospadias repair, n=37\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003eDistal penile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e56.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003eMid/Proximal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e43.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocation of UCF, n=42\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003eDistal penile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e92.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003eMid/Proximal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e7.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTechnique of hypospadias repair\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003eTIP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e59.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003eTwo-stage repairs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e29.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003eOther techniques**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e11.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime from hypospadias repair to UCF repair\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003e\u0026pound;6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e22.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003e7-12months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e34.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003e\u0026gt;12 months\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e43.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003eMedian(range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e14(13.5-30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of urethral catheter/stent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003e\u0026pound;7 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e27.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003e\u0026gt;7 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e72.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003eMedian(range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e12(7.5-25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTechnique used for 1st UCF repair\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003eMultilayer repair\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e86.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003eSimple\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003eOther techniques***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuture material\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003eVicryl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003eMonocryl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e13.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003eBiosyn/PDS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e11.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuture size\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003esize 4-0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e15.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003esize 5-0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e47.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003esize 6-0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 145px;\"\u003e\n \u003cp\u003e36.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Other regions- Morogoro (3), Mwanza (2), Tabora (2), Mbeya 1, Kigoma (1), Tanga (1).\u003c/p\u003e\n\u003cp\u003e**Other techniques for hypospadias repair \u0026ndash; Duckett repair 2, Mathieu repair 3\u003c/p\u003e\n\u003cp\u003e***Other technique for UCF repair \u0026ndash; Coronal fistula converted to coronal hypospadias and repaired (4).\u003c/p\u003e\n\u003cp\u003eEUM-External urethra meatus; PDS-Polydioxanone suture TIP- Tubularized incised plate; UCF-Urethrocutaneous fistula\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ch2 id=\"_Toc171611363\"\u003eRecurrence rate of Urethrocutaneous Fistula\u003c/h2\u003e\n\u003cp\u003eAmong the 44 patients who underwent UCF repair, recurrence occurred 30% after the first attempt. Subsequent repairs showed recurrence rates of 30% for the second repair and 50% for the third, while no recurrences occurred after the fourth repair. Recurrence was more frequent in younger children (\u0026le;5 years) 37.9% (11 of 29), mid/proximal hypospadias 56.2%(9 of 16), longer catheter duration (\u0026gt;7 days) 34.3%(11 of 32), multilayer closure 34.2%(13 of 38), and use of 5/0 suture size 33.3%(7 of 21). However, on univariate analysis, only the type of hypospadias (p=0.007) and location of the fistula (p=0.027) were statistically significant predictors of recurrence. Other factors including age, hypospadias repair technique, catheter duration, and suture type or size did not show significant associations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2: Characteristics of determinants of UCF recurrence after repair\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"645\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUCF Recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal, n(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes, n(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo, n(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026pound; 5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e29 (65.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e11 (84.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e18 (58.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026gt;5years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e15 (34.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e2 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e13 (41.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocation of EUM at hypospadias repair, n=37\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eDistal penile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e21 (56.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e3 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e18 (72.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eMid/proximal penile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e16 (43.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e9 (75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e7 (28.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocation of UCF n=42\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eMid/proximal penile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e0\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e3 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eDistal penile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e39 (92.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e12 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e27 (90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTechnique of hypospadias repair\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.118\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eOther technique*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e31(70.45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e7(53.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e24(77.42%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eTwo-stage repairs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e13(29.55%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e6(46.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e7(22.58%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime from hypospadias repair to UCF repair\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.905\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u0026le;6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e10 (22.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e3 (23.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e7 (22.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003e7\u0026ndash;12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e15 (34.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e5 (38.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e10 (32.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u0026gt;12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e19 (43.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e5 (38.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e14 (45.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of urethral catheter/stent\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.252\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u0026pound;\u0026nbsp;7 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e12 (27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e2 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e10 (32.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u0026gt;7 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e32 (72.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e11 (84.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e21 (67.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTechnique used for 1\u003csup\u003est\u003c/sup\u003e UCF repair\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.233\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eMultilayer repair\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e38 (86.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e13 (100.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e25 (80.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eSimple repair\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e0\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e2 (6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eOther techniques**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4 (9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e0\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e4 (12.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuture material\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eMonocryl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e6 (13.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e1 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e5 (16.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eBiosyn/PDS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5 (11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e1 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e4 (12.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003eVicryl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e33 (75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e11 (84.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e22 (71.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Suture size\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.441\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003esize 4/0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e7 (15.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e3 (23.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e4 (12.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003esize 5/0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e21 (47.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e7 (53.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e14 (45.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 270px;\"\u003e\n \u003cp\u003esize 6/0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e16 (36.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e3 (23.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 130px;\"\u003e\n \u003cp\u003e13 (41.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Other techniques for hypospadias repair \u0026ndash; TIP (26), Duckett repair (2), Mathieu repair (3),\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e**Other technique for UCF repair - coronal fistula converted to coronal hypospadias and repaired (4).\u003c/p\u003e\n\u003cp\u003eEUM-External urethra meatus; PDS-Polydioxanone suture TIP- Tubularized incised plate; UCF-Urethrocutaneous fistula\u003c/p\u003e\n\u003ch2 id=\"_Toc171611364\"\u003eDeterminants of recurrence of UCF after repair\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eBy bivariate analysis, distal penile fistula and proximal hypospadias had a significantly higher risk of recurrent fistula [RR; 1.23, 95% CI(1.17-4.51), p =0.027] and [RR; 7.71, 95% CI1(1.6-37.13), p =0.011] respectively as compared to their counterparts. \u0026nbsp;Age, previous technique of hypospadias repair, time from hypospadias repair to UCF repair, suture material, and suture size were not significantly associated with UCF recurrence (p\u0026gt; 0.05)\u003c/p\u003e\n\u003cp\u003eIn multivariate regression analysis, after adjusting all variables in the model, still, patients who had distal urethracutaneous fistula had a statistically significant higher risk of fistular recurrence after repair. [Adjusted RR;1.73, 95% CI(1.53-2.20), p = 0.048]. \u0026nbsp;Patients who had distal penile hypospadias had a significantly lower risk for recurrence [Adjusted RR; 4.21, 95% CI(1.31-17.20), p =0.029] as compared to their counterparts with mid/proximal penile hypospadias (\u003cem\u003eTable 3).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTable 3: \u0026nbsp;Multivariate analysis on determinants of UCF recurrence after repair\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"656\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003eCRUDE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\n \u003cp\u003eADJUSTED\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003eRR(95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003ep-Value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\n \u003cp\u003eRR(95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003ep-Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u0026pound;5years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u0026gt;5years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003e0.25(0.04-1.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0.105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\n \u003cp\u003e0.20 (0.01\u0026ndash;2.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.236\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocation of UCF, n=42\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eMid/proximal penile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eDistal Penile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e1.23(1.17-4.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e1.73(1.53-3.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.048\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocation of EUM at Hypospadias repair\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003eDistal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003eMid/Proximal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003e7.71(1.6-37.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0.011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\n \u003cp\u003e4.21(1.31-17.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTechnique hypospadias repair\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003e*Other techniques\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003eTwo-stage repairs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003e0.34(0.08-1.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0.125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\n \u003cp\u003e1.71 (0.10\u0026ndash;30.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.715\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime for Hypospadias repair to UCF repair\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u0026le;6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003e7\u0026ndash;12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003e1.16(0.20-6.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0.861\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\n \u003cp\u003e4.75 (0.20\u0026ndash;11.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.334\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u0026gt;12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003e0.83(0.15-4.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0.833\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\n \u003cp\u003e3.73 (0.25\u0026ndash;15.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration catheter after UCF repair\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u0026pound;7 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u0026gt;7 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003e2.61(0.48-14.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0.263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\n \u003cp\u003e5.70 (0.25\u0026ndash;13.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.277\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTechnique used for 1st UCF repair\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003e**Other techniques\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003eMultilayer repair\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003e6.88(0.35-13.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\n \u003cp\u003e13.04 (0.24\u0026ndash;71.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.209\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuture Material Used for UCF Repair\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003eMonocryl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003eBiosyn/PDS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003e1.25(0.05-26.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0.887\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\n \u003cp\u003e10.20 (0.05\u0026ndash;18.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.384\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003eVicryl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003e2.5(0.25-24.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0.428\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\n \u003cp\u003e4.93 (0.21\u0026ndash;11.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.325\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuture size used for UCF repair\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003esize 4-0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003esize 5-0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003e0.66(0.12-3.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\n \u003cp\u003e1.08 (0.04\u0026ndash;28.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.963\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003esize 6-0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 118px;\"\u003e\n \u003cp\u003e0.30(0.04-2.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0.237\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\n \u003cp\u003e0.15 (0.00\u0026ndash;6.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.326\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eP-value, RR-Relative risk, CI-Confidence Interval, adjusted run for all independent variable\u003c/p\u003e\n\u003cp\u003e*Other techniques for hypospadias repair \u0026ndash; TIP, Duckett repair, Mathieu repair\u003c/p\u003e\n\u003cp\u003e**Other technique for UCF repair - Simple repair, coronal fistula converted to coronal hypospadias and repaired.\u003c/p\u003e\n\u003cp\u003eEUM-External urethra meatus; PDS-Polydioxanone suture, TIP- Tubularized incised plate; UCF-Urethrocutaneous fistula\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eManagement of urethrocutaneous fistulas (UCF) after hypospadias repair remains a significant problem, with studies indicating variable recurrence rates ranging from 0% to 28%,\u0026nbsp;[21,25,26]\u0026nbsp;influenced by different factors. This study, being the first of its kind in Tanzania, reported an overall recurrence rate of 30%, with 13 out of 44 patients experiencing recurrence after the first repair, and subsequently, 4 out of those 13 having recurrence after the second repair.\u003c/p\u003e\n\u003cp\u003eThe findings align with a study conducted in the USA, which documented recurrence rates of 28% after the first repair and 33% after the second [30]. A noteworthy observation from this study is that prior UCF repair did not seem to impact the recurrence rates of subsequent repairs, which is consistence with previous published reports [21,31].\u003c/p\u003e\n\u003cp\u003eConversely, several prior studies have reported lower recurrence rates. For instance, a study noted a 6% recurrence rate (2/32) after a tunica vaginalis flap (TVF) repair [6], and another study highlighted a 13% recurrence rate (2/15) following the\u0026nbsp;Preserve the Tract and Turn it Inside Out (PATIO) repair method\u0026nbsp;[32]. Low recurrence rates in these studies may be attributed to the surgeon\u0026rsquo;s familiarity with a single surgical technique which increases standardization and consistency. However, this discrepancy in recurrence rates emphasizes the need for further research to identify the determinants influencing UCF recurrence in various populations and surgical techniques.\u003c/p\u003e\n\u003cp\u003eIn this index study, the recurrence of UCF after repair was significantly associated with a previous history of proximal hypospadias and distal fistula location. Patients with previous history of proximal hypospadias have a higher risk of fistula recurrence which may be due to the complex tissue mobilization required for neo-meatus placement at the tip. Staged repairs which are done for most proximal hypospadias can compromise surrounding tissues needed for subsequent fistula repair[21]. Another study identified the type of hypospadias as an independent risk factor for failed UCF repair, with penoscrotal hypospadias having a higher rate of failure of UCF repair [28].\u003c/p\u003e\n\u003cp\u003eA similar study has shown that distal fistulas are associated with a higher recurrence rate compared to proximal ones\u0026nbsp;[14]. This may be due to the fragility of the distal penile skin, compromised blood supply from previous surgeries, and traction at the coronal sulcus\u0026mdash;particularly during erections in the early postoperative period. Moreover, this anatomical region lacks sufficient tissue for a second-layer closure, further complicating repair efforts [24]. The use of simple repair techniques at this site has also been linked to increased recurrence. Hence distal UCFs, especially those located at the coronal sulcus, are particularly challenging to manage. Previous studies recommend avoiding simple repair techniques in these cases and instead advocate for the use of advancement or rotational flaps to improve surgical outcomes\u0026nbsp;[14].\u0026nbsp;However, when the distal fistula is large, it is better to connect it to the distal meatus and convert it to hypospadias and be repaired by tubularization of the urethral plate and multilayer coverage with healthy tissues\u0026nbsp;[27]. In our study, four coronal UCFs were converted to coronal hypospadias and repaired without recurrence.\u0026nbsp;Success in repairing proximal fistulas may be attributed to the meticulous surgical techniques employed and the careful selection of well-vascularized flaps. For instance, two cases of proximal UCF were successfully repaired using the tunica vaginalis flap, which provides robust vascular support. Additionally, the low recurrence rate in this group might also be influenced by the relatively small number of patients.\u0026nbsp;Other studies have shown no significant difference in recurrence among distal and proximal UCF\u0026nbsp;[17,33\u0026ndash;35].\u003c/p\u003e\n\u003cp\u003eVarious techniques for correcting UCF have been studied, demonstrating variable success rates influenced by factors such as the number, size, location of the fistula, and the nature of surrounding tissues [36][26][37][7][16][38]. Multilayer repair utilizing flaps, such as penile dartos or tunica vaginalis, and grafts like buccal mucosa or synthetic materials, is effective with a low recurrence rate. In our study, the majority of fistulas were repaired using multilayer repair with penile dartos as an intermediate layer\u0026mdash;a straightforward technique. Urethral calibration was often performed to assess for strictures or meatal stenosis before proceeding with repairs. If a stricture was identified during calibration, it was typically repaired first to ensure proper functionality of the urethra before UCF repair \u0026nbsp; \u0026nbsp;While most previous studies indicate that the multilayer closure method typically has a low recurrence rate [26,39], our findings showed a higher recurrence rate in multilayer repairs compared to other techniques; however, this difference was not statistically significant. This observation may be attributed to the use of poorly vascularized flaps with flap necrosis, scar tissues, and the limited number of patients repaired using alternative techniques. Various other techniques such as PATIO, \u0026nbsp;Multilayer Direct Closure With a Longitudinal Relaxing Incision, the use of buccal mucosa, and \u0026nbsp;synthetic graft have shown promising results with success in UCF repair, these highlight the need for more standardized and individualized approaches in UCF repair[25,32,38,40]\u003c/p\u003e\n\u003cp\u003eThe history of previous hypospadias surgeries may impact the recurrence of UCF, as extensive procedures involving significant tissue mobilization can compromise the blood supply to the periurethral area, affecting subsequent UCF repairs. Waterman et al. demonstrated that the King and Yoke technique resulted in lower fistula recurrence, likely due to reduced tissue mobilization and preserved ventral blood supply [21]. In our study, while the tubularized incised plate (TIP) technique was predominantly utilized compared to staged repair, Mathieu, and Duckett techniques, variations in these surgical approaches did not significantly influence UCF recurrence.\u003c/p\u003e\n\u003cp\u003eUCF repair is generally recommended at least 6 months after the primary hypospadias surgery to allow for proper healing, reduced scarring, and improved skin vascularization around the fistula site as reported by previously published data [26,41]. In this study: The median time from initial surgery to UCF repair was 14 months, 10 patients (22.7%) had repairs done within six months. One case repaired at two months recurred. Repairs at 4 and 5 months did not recur. No statistically significant difference in recurrence was found between those repaired before or after 6 months.\u003c/p\u003e\n\u003cp\u003eThis aligns with findings by \u003cem\u003eWatermal et al,\u003c/em\u003e who also saw no significant difference in success rates between early (3.7\u0026ndash;6 months) and later repairs (\u0026ge;6 months) [21]. While our data doesn\u0026rsquo;t show a significant statistical difference, waiting at least 6 months remains the preferred approach to optimize outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the current study, the type of suture material did not significantly impact the UCF recurrence after repair, this aligns with the study done by \u003cem\u003eWahyudi et al\u003c/em\u003e which found no significant difference in complication rates between absorbable synthetic braided and monofilament during urethra surgery [42]. Furthermore, the suture material showed no significant impact on UCF recurrence possibly because other factors like suturing technique, tissue handling, and tissue health play a more crucial role in fistula closure.\u003c/p\u003e\n\u003cp\u003eThe use of a catheter/stent during UCF repair is a topic of debate. Despite varying durations of catheter/stent ranging from 1 to 30 days in all UCF repairs in this study, there was no significant difference in recurrence among the different groups. \u003cem\u003eWaterman et al\u003c/em\u003e concluded in their study that there was no clear difference in recurrence between using a stent versus not using a stent during UCF repair [21]. On the other hand, \u003cem\u003eDekalo et al\u0026nbsp;\u003c/em\u003edid not view the use of a catheter/stent as a preferable option for UCF repair [34]. We used a urethral catheter/stent for all our patients undergoing UCF repair because we believed that it prevents urine extravasation to the surgical site, prevents post-operative dysuria, and supports urethral healing. \u0026nbsp;\u003c/p\u003e\n\u003cp id=\"_Toc171611367\"\u003e\u003cstrong\u003eStrength and Limitation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is the first study to report the recurrence rate of UCF after repair in Tanzania it also highlighted the key determinants that influence the recurrence of UCF after repair.\u003c/p\u003e\n\u003cp\u003eAlthough the findings of this study are comparable to many other similar studies, these findings should be discussed in light of the following limitations; Firstly, the retrospective nature of the study which led to missing patients\u0026rsquo; files and some variables and hence ended up with the small sample size, that might have caused overestimation of the proportions. Inconsistent documentation led to missing important variables for analysis such as surgeon experience, intraoperative tissue handling, number and size of fistula, suturing technique, and many others which may impact UCF repair. Secondly, the study was conducted in a single center which limits the generalizability of the findings to a broader population. However, the findings can be generalized to a setting with a similar context.\u003c/p\u003e"},{"header":"Conclusions and Recommendation","content":"\u003cp\u003eUCF following hypospadias repair is associated with frequency recurrence. In this study, the recurrence rate of UCF after the repair is 30% (13 of 44), 30% (4 of 13), 50% (2 of 4), and none in the 1\u003csup\u003est\u003c/sup\u003e, 2\u003csup\u003end\u003c/sup\u003e, 3\u003csup\u003erd,\u003c/sup\u003e and 4\u003csup\u003eth\u003c/sup\u003e repair respectively.\u003c/p\u003e\n\u003cp\u003eRecurrence of UCF after surgical repair is significantly influenced by history of proximal hypospadias and having distal UCF. Hence before attempting to repair, thorough patient evaluation should be done. Addressing these issues is crucial in developing a strategy to mitigate recurrence and improve surgical outcomes among patients undergoing UCF repair. Furthermore, all confounding factors cannot completely be excluded, a further prospective study with a large number sample size should be conducted to validate these findings and explore additional factors influencing UCF recurrence\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eThe administration of Kilimanjaro Christian Medical Center allows the use of the hospital medical records, the Kilimanjaro Christian Medical University College for providing ethical clearance, and all staff from the Urology department.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u0026nbsp;\u003c/strong\u003eAuthors have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNyamhanga Nsaho Maro:\u0026nbsp;\u003c/strong\u003eWriting \u0026ndash; original draft.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFrank Bright\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eWriting \u0026ndash; review and editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOrgeness Mbwambo\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eWriting \u0026ndash; review and editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJaspar Mbwambo\u003c/strong\u003e: Writing- review and editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBartholomeo Nicholaus Ngowi\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eSupervision; writing \u0026ndash; original draft.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThere was no funding for this research\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data materials\u003c/strong\u003e: The dataset used during the present study is available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003c/strong\u003e\u003cstrong\u003econsent to participate:\u0026nbsp;\u003c/strong\u003eEthical approval number PG 98/2023 was obtained from Kilimanjaro Christian Medical University College Research and Ethical Review Committee.\u0026nbsp;All enrolled patients gave written general informed consent for the future use of data/materials for research; in the case of patients younger than 18 years, consents were signed by both the patient and one of their parents.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: Not Applicable. Patient identity did not appear in any part of the manuscript; therefore, consent for publication was not required.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLucas T, Hines JZ, Samuelson J, Hargreave T, Davis SM, Fellows I, et al. Urethrocutaneous fistulas after voluntary medical male circumcision for HIV prevention\u0026mdash;15 African Countries, 2015\u0026ndash;2019. BMC Urol 2021;21. https://doi.org/10.1186/s12894-021-00790-y.\u003c/li\u003e\n\u003cli\u003eKoul A, Shukla D, Aggrawal SK, Sethi N. Incidence of urethrocutaneous fistula following distal hypospadias repair with and without caudal epidural block: A randomized pilot study. J Pediatr Urol 2022;18:58.e1-58.e7. https://doi.org/10.1016/j.jpurol.2021.11.006.\u003c/li\u003e\n\u003cli\u003eJumbi T, Shahbal S, Mugo R, Osawa F, Mwika P, Lessan J. Urethro-cutaneous Fistula after Hypospadia Repair: A single institution study. Ann African Surg 2019;16:59\u0026ndash;63. https://doi.org/10.4314/aas.v16i2.4.\u003c/li\u003e\n\u003cli\u003eMohammed M, Bright F, Mteta A, Mbwambo J, Ngowi BN, Mbwambo O, et al. Long-Term Complications of Hypospadias Repair: A Ten-Year Experience from Northern Zone of Tanzania. Res Reports Urol 2020; Volume 12:463\u0026ndash;9. https://doi.org/10.2147/RRU.S270248.\u003c/li\u003e\n\u003cli\u003eAwad MS. A simple novel technique [PUIT] for closure of urethrocutaneous fistula after hypospadias repair: Preliminary results. Indian J Plast Surg 2005;38:114\u0026ndash;8. https://doi.org/10.4103/0970-0358.19778.\u003c/li\u003e\n\u003cli\u003eBhat S, Nair C, Shetty S, Paul F. Tunica Vaginalis Flap Repair for Urethrocutaneous Fistulae. J Clin Diagnostic Res 2019;13:2017\u0026ndash;9. https://doi.org/10.7860/jcdr/2019/42702.13364.\u003c/li\u003e\n\u003cli\u003eJamal YS, Kurdi MO, Moshref SS. Management of Small Urethrocutaneous Fistula by Tight Ligation with Fulguration of the External Epithelium of the Tract 2010;6:150\u0026ndash;3.\u003c/li\u003e\n\u003cli\u003eObi AO. Traumatic urethrocutaneous fistula: Case report and literature review. African J Urol 2013;19:198\u0026ndash;201. https://doi.org/10.1016/j.afju.2013.07.002.\u003c/li\u003e\n\u003cli\u003eBhari N, Jangid BL, Singh S, Mittal S, Ali F, Yadav S. Urethrocutaneous fistula: a rare presentation of penile tuberculosis. Int J STD AIDS 2017;28:97\u0026ndash;9. https://doi.org/10.1177/0956462416647624.\u003c/li\u003e\n\u003cli\u003eGalinier P, Mouttalib S, Carfagna L, Vaysse P, Moscovici J. Congenital anterior urethrocutaneous fistula associated with a stenosis of the bulbar urethra in the context of high anorectal malformation without fistula. J Plast Reconstr Aesthetic Surg 2009;62. https://doi.org/10.1016/j.bjps.2008.04.050.\u003c/li\u003e\n\u003cli\u003eGarg G, Mehdi S, Bansal N, Sankhwar S. Squamous cell carcinoma of male urethra presenting as urethrocutaneous fistula. BMJ Case Rep 2018;2018. https://doi.org/10.1136/bcr-2018-227447.\u003c/li\u003e\n\u003cli\u003eHattori Y, Yamashita S, Morishita Y, Iida T. Effective Secondary Reconstruction of Refractory Urethrocutaneous Fistula after Metoidioplasty Using Folded Superficial Circumflex Iliac Artery Perforator Flap. Plast Reconstr Surg - Glob Open 2020;8:E2716. https://doi.org/10.1097/GOX.0000000000002716.\u003c/li\u003e\n\u003cli\u003eChung JW, Choi SH, Kim BS, Chung SK. Risk factors for the development of urethrocutaneous fistula after hypospadias repair: A retrospective study. Korean J Urol 2012;53:711\u0026ndash;5. https://doi.org/10.4111/kju.2012.53.10.711.\u003c/li\u003e\n\u003cli\u003eElbakry A. Management of urethrocutaneous fistula after hypospadias repair: 10 Years\u0026rsquo; experience. BJU Int 2001;88:590\u0026ndash;5. https://doi.org/10.1046/j.1464-4096.2001.02390.x.\u003c/li\u003e\n\u003cli\u003eShirazi M, Ariafar A, Babaei AH, Ashrafzadeh A, Adib A. A simple method for closure of urethrocutaneous fistula after tubularized incised plate repair: Preliminary results. Nephrourol Mon 2016;8. https://doi.org/10.5812/numonthly.40371.\u003c/li\u003e\n\u003cli\u003eLandau EH, Gofrit ON, Meretyk S, Katz G, Golijanin D, Shenfeld OZ, et al. Outcome analysis of tunica vaginalis flap for the correction of recurrent urethrocutaneous fistula in children. J. Urol., vol. 170, Lippincott Williams and Wilkins; 2003, p. 1596\u0026ndash;9. https://doi.org/10.1097/01.ju.0000084661.05347.58.\u003c/li\u003e\n\u003cli\u003eSrivastava RK, Tandale MS, Panse N, Gupta A, Sahane P. Management of urethrocutaneous fistula after hypospadias surgery - An experience of thirty-five cases. Indian J Plast Surg 2011;44:98\u0026ndash;103. https://doi.org/10.4103/0970-0358.81456.\u003c/li\u003e\n\u003cli\u003eYassin T, Bahaaeldin KH, Husein A, El Minawi H. Assessment and management of urethrocutaneous fistula developing after hypospadias repair. Ann Pediatr Surg 2011;7:88\u0026ndash;93. https://doi.org/10.1097/01.XPS.0000397066.98404.82.\u003c/li\u003e\n\u003cli\u003eOchi T, Seo S, Yazaki Y, Okawada M, Doi T, Miyano G, et al. Traction-assisted dissection with soft tissue coverage is effective for repairing recurrent urethrocutaneous fistula following hypospadias surgery. Pediatr Surg Int 2015;31:203\u0026ndash;7. https://doi.org/10.1007/s00383-014-3652-1.\u003c/li\u003e\n\u003cli\u003ePescheloche P, Parmentier B, Hor T, Chamond O, Chabaud M, Irtan S, et al. Tunica vaginalis flap for urethrocutaneous fistula repair after proximal and mid-shaft hypospadias surgery: A 12-year experience. J Pediatr Urol 2018;14:421.e1-421.e6. https://doi.org/10.1016/j.jpurol.2018.03.026.\u003c/li\u003e\n\u003cli\u003eWaterman BJ, Renschler T, Cartwright PC, Snow BW, DeVries CR. Variables in successful repair of urethrocutaneous fistula after hypospadias surgery. J Urol 2002;168:726\u0026ndash;30. https://doi.org/10.1016/s0022-5347(05)64734-9.\u003c/li\u003e\n\u003cli\u003eShehata SM. Use of the TIP principle for the repair of non-glanular recurrent post hypospadias urethrocutaneous mega fistula. Eur J Pediatr Surg 2009;19:395\u0026ndash;8. https://doi.org/10.1055/s-0029-1243170.\u003c/li\u003e\n\u003cli\u003eAldaqadossi HA, Eladawy M, Shaker H, Kotb Y, Azazy S. Tunica vaginalis graft for recurrent urethrocutaneous fistula repair after hypospadias surgery. Int J Urol 2020;27:726\u0026ndash;30. https://doi.org/10.1111/iju.14287.\u003c/li\u003e\n\u003cli\u003eSnyder CL, Evangelidis A, Hansen G, St. Peter SD, Ostlie DJ, Gatti JM, et al. Management of complications after hypospadias repair. Urology 2005;65:782\u0026ndash;5. https://doi.org/10.1016/j.urology.2004.11.037.\u003c/li\u003e\n\u003cli\u003eChen 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;84:317\u0026ndash;21. https://doi.org/10.1097/SAP.0000000000002056.\u003c/li\u003e\n\u003cli\u003eBiswas A, Kmd I, Chaki A, Akmk B, Mz H. Original Article Result of simple versus layered repair of urethro-cutaneous fistula developing after hypospadias surgery. J Paediatr Surg Bangladesh 2019;10:37\u0026ndash;42.\u003c/li\u003e\n\u003cli\u003eRichter F, Pinto PA, Stock JA, Hanna MK. Management of recurrent urethral fistulas after hypospadias repair. Urology 2003;61:448\u0026ndash;51. https://doi.org/10.1016/S0090-4295(02)02146-5.\u003c/li\u003e\n\u003cli\u003eAbdullaev Z, Agzamkhodjaev S, Chung JM, Lee SD. Risk factors for fistula recurrence after urethrocutaneous fistulectomy in children with hypospadias. Turkish J Urol 2021;47:237\u0026ndash;41. https://doi.org/10.5152/tud.2020.20323.\u003c/li\u003e\n\u003cli\u003eMremi A, Mswima J, Mlay MG, Bartholomew H, Julius P, Mmbaga BT, et al. experience in Tanzania 2023. https://doi.org/10.1016/j.ctarc.2020.100213.Cancer.\u003c/li\u003e\n\u003cli\u003eHolland AJA, Abubacker M, Smith GHH, Cass DT. Management of urethrocutaneous fistula following hypospadias repair. Pediatr Surg Int 2008;24:1047\u0026ndash;51. https://doi.org/10.1007/s00383-008-2202-0.\u003c/li\u003e\n\u003cli\u003eSunay M, Dadali M, Karabulut A, Emir L, Erol D. Our 23-Year Experience in Urethrocutaneous Fistulas Developing After Hypospadias Surgery. Urology 2007;69:366\u0026ndash;8. https://doi.org/10.1016/j.urology.2006.12.012.\u003c/li\u003e\n\u003cli\u003eRathod K, Loyal J, More B, Rajimwale A. Modified PATIO repair for urethrocutaneous fistula post-hypospadias repair: operative technique and outcomes. Pediatr Surg Int 2017;33:109\u0026ndash;12. https://doi.org/10.1007/s00383-016-3983-1.\u003c/li\u003e\n\u003cli\u003eFeng J, Yang Z, Tang Y, Chen W, Zhao MX, Ma N, et al. Risk Factors for Urethrocutaneous Fistula Repair after Hypospadias Surgery: A Retrospective Study. Ann Plast Surg 2017;79:e41\u0026ndash;4. https://doi.org/10.1097/SAP.0000000000001128.\u003c/li\u003e\n\u003cli\u003eDekalo S, Ben-David R, Bar-Yaakov N, Dubi-Sobol A, Ekstein M, Ben-Chaim J, et al. In Support of a Simple Urethrocutaneous Fistula Closure Technique Following Hypospadias Repair. Urology 2020;143:212\u0026ndash;5. https://doi.org/10.1016/j.urology.2020.06.015.\u003c/li\u003e\n\u003cli\u003eMalhotra NR, Schaeffer AJ, Slade AD, Cartwright PC, Lau GA. Post-hypospadias urethrocutaneous fistulae: no difference in repair success between proximal and distal fistulae. Can J Urol 2020;27:10466\u0026ndash;70.\u003c/li\u003e\n\u003cli\u003eSingh A, Shukla A, Sharma P, Barolia D. A simple procedure for management of urethrocutaneous fistula after hypospadias repair. Menoufia Med J 2019;32:1223. https://doi.org/10.4103/mmj.mmj_213_18.\u003c/li\u003e\n\u003cli\u003eShaw NM, Mallahan C, Joshi P, Venkatesan K, Kulkarni S. Novel use of Asopa technique for penile urethrocutaneous fistula repair. Int Urol Nephrol 2021;53:1127\u0026ndash;33. https://doi.org/10.1007/s11255-020-02767-6.\u003c/li\u003e\n\u003cli\u003eTawfeek AM, Mohareb AM, Higazy A, Farouk A, Elsaeed KO, Tawfick A, et al. Isoamyl 2-cyanoacrylate interposition in the urethro-cutaneous fistula repair: A randomized controlled trial. African J Urol 2021;27. https://doi.org/10.1186/s12301-021-00197-z.\u003c/li\u003e\n\u003cli\u003eCimador M, Castagnetti M, De Grazia E. Urethrocutaneous fistula repair after hypospadias surgery. BJU Int 2003;92:621\u0026ndash;3. https://doi.org/10.1046/j.1464-410X.2003.04437.x.\u003c/li\u003e\n\u003cli\u003eHosseini J, Kaviani A, Mohammadhosseini M, Rezaei A, Rezaei I, Javanmard B. Fistula repair after hypospadias surgery using a buccal mucosal graft. Urol J 2009;6:19\u0026ndash;22.\u003c/li\u003e\n\u003cli\u003eHan W, Zhang W, Sun N. Risk factors for failed urethrocutaneous fistula repair after transverse preputial island flap urethroplasty in pediatric hypospadias. Int Urol Nephrol 2018;50:191\u0026ndash;5. https://doi.org/10.1007/s11255-017-1773-x.\u003c/li\u003e\n\u003cli\u003eWahyudi I, Angga P, Raharja R, Situmorang GR, Rodjani A. Journal of Pediatric Surgery Open Associations between suturing techniques and suture materials with complications of tubularised incised plate urethroplasty : A systematic review and meta-analysis 2023;1. https://doi.org/10.1016/j.yjpso.2023.100003.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Hypospadias, Urethrocutaneous fistula, Recurrance","lastPublishedDoi":"10.21203/rs.3.rs-5813275/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5813275/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eUrethrocutaneous fistula (UCF) is a common complication following hypospadias repair that may be associated with frequent recurrences after repair and ultimately increases treatment costs and poor cosmetic outcomes due to multiple surgeries.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim\u003c/strong\u003e: To evaluate the recurrence rate of post hypospadias urethrocutaneous fistula and its determinants following repair among patients treated at the urology department of Kilimanjaro Christian Medical Centre from January 2011 to December 2023\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology\u003c/strong\u003e: We conducted a hospital-based retrospective study that reviewed case notes of all patients who developed UCF post-hypospadias repair. Patients were followed for at least six months postoperatively and various factors were analyzed to check for their influence on recurrence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The study included 44 patients with urethrocutaneous fistula after hypospadias repair. The recurrence rates after repair were 30% (13 of 44), 30% (4 of 13), 50% (2 of 4), and none in the 1st, 2nd, 3rd, and 4th repairs, respectively. In the bivariate analysis, recurrence was statistically associated with the history of previous proximal hypospadias, distal urethrocutaneous fistula, and multilayer repair technique. However, in the multivariate analysis, only the history of previous proximal hypospadias and distal location of the fistula were significant independent determinants of recurrence (p \u0026lt; 0.005).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: UCF post hypospadias repair is associated with at least one-third of recurrence following repair. Proximal hypospadias and distal UCF are significantly associated with a high recurrence rate following UCF. Addressing these issues is crucial in developing a strategy to mitigate recurrence and improve surgical outcomes among patients undergoing UC repair.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: Not applicable\u003c/p\u003e","manuscriptTitle":"Urethrocutaneous Fistula Following Hypospadias Repair: Recurrence Rate and Its Determinants","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-22 14:37:45","doi":"10.21203/rs.3.rs-5813275/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"01be2fe0-797f-4015-ab1b-4d7eae995b22","owner":[],"postedDate":"April 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-04T18:38:24+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-22 14:37:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5813275","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5813275","identity":"rs-5813275","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}
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