Predictors of Treatment Failure in Urethrocutaneous Fistula Repair for Hypospadias: A Retrospective Analysis

Predictors of Treatment Failure in Urethrocutaneous Fistula Repair for Hypospadias: A Retrospective Analysis | 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 Predictors of Treatment Failure in Urethrocutaneous Fistula Repair for Hypospadias: A Retrospective Analysis Ye Zhang, Qihang Sun, Kaiping Zhang, Yin Zhang, Jiabin Jiang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4658990/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 Purpose This study aimed to identify risk factors associated with the recurrence of urethrocutaneous fistula (UCF) following repair in patients with hypospadias, beyond the intrinsic characteristics of the fistula itself. Methods Clinical data of patients who underwent UCF repair were retrospectively reviewed. Potential risk factors included age and body mass index at UCF repair, history of low birth weight and prematurity, urethral defect length, operative approaches and urethral covering during hypospadias repair (HR), interval between urethroplasty and UCF presentation, interval between urethroplasty and UCF repair, meatal stenosis, size, number and location of UCFs. Univariate and multivariate analysis were used to identify the risk factors of UCF recurrence. Results A total of 136 patients underwent UCF repair from 2013 to 2022, and UCF recurred in 31 patients (22.8%) after a median follow-up of 36.2 months. Results of multivariate analysis showed that the UCF with a diameter exceed 4mm ( OR 6.968, 95% CI 1.522–31.898, P =0.012), multiple UCFs ( OR 4.017, 95% CI 1.284–12.571, P =0.017), coronal UCF ( OR 2.964, 95% CI 1.142–7.695, P =0.026) and urethral covering with non-Buck’s fascia ( OR 2.631, 95% CI 1.015–6.819, P =0.047) were statistically significant, correlating with the risk of UCF recurrence. Conclusion UCF repair was more prone to failure if the size of UCF exceeds 4 mm, if it is located at the coronary sulcus, if multiple UCFs are present. Employing Buck’s fascia during HR would reduce the incidence of UCF recurrence. urethrocutaneous fistula hypospadias risk factors child recurrence Introduction Urethrocutaneous fistula (UCF) represents the most prevalent complication post-hypospadias repair (HR), with incidence rates varying widely from 0–45% across the published literature [ 1 ]. The presence of UCF is frequently employed as a measure of HR success. Numerous surgical techniques, such as simple classical closure, double ligation, and V-Y advanced skin flap, have been extensively documented for managing UCF based on its unique characteristics. The core tenets of UCF repair encompass tension-free closure, multilayer covering, appropriate suture selection, and correction of any associated urethral stricture. However, UCF recurs approximately 20% of the time [ 2 ]. A recent meta-analysis of 2886 patients who underwent UCF repair found that 539 experienced recurrences, with success rates for different approaches ranging from 54.5–100% [ 3 ]. Various risk factors for recurrent UCF have been explored, apart from the characteristic of UCF itself, such as the type of hypospadias, the length of urethral defect, and urethral operation history [ 4 – 6 ]. Drawing from our clinical experience, the efficacy of UCF repair appears to hinge primarily on the UCF’s intrinsic nature rather than extraneous elements. Given that Buck’s fascia, utilized as a critical coverage in HR, has effectively reduced the incidence of UCF in our institution, we hypothesize that is may also exerts a positive effect on post UCF repair outcomes. To validate this hypothesis, we have conducted a retrospective evaluation of a decade-long UCF repair practice to delineate predictors of UCF recurrence. Materials and methods This retrospective study was conducted in accordance with the Declaration of Helsinki and received ethical approval from the Institutional ethical committee of Anhui Children’s Hospital (IRB number: EYLL-2023-021). We revised the clinical data of patients who underwent UCF repair after HR and were admitted to our institution between January 2013 and December 2022. Missing information was obtained through telephone interviews with informed consent from their guardians. Concomitant meatal stenosis was defined by symptoms such as a narrow urinary stream or dysuria, and the diagnosis was confirmed through intraoperative evaluation of the meatal size. We applied the following exclusion criteria: (1) patients with other urethral complications, such as urethral stricture or urethral diverticulum, since correction of these complications simultaneously may require redo-urethroplasty; (2) patients with coronal UCF combined with glans dehiscence who underwent redo-urethroplasty such as TIP (tubularized incised plate) urethroplasty or Mathieu urethroplasty; (3) patients with follow-up periods of less than 6 months since their last operations; (4) patients with incomplete clinical information. All operations were performed under general anesthesia combined with a caudal block at least six months after HR. Before UCF repair, indigo carmine blue solution was injected into the meatus, meanwhile, a tourniquet was applied around the base of the penis to occlude the urethra, preventing the omission of small UCFs. The diameter of the UCF was measured using a ruler. The epithelialized tract to the urethra was excised, and the urothelial edges of UCF were closed in a subepithelial fashion. All UCFs were overlaid with vascularized tissue, such as a local dartos flap. Skin closure was performed using a Y-V advanced skin flap to avoid overlapping sutures. In cases with meatal stenosis, meatoplasty was preformed simultaneously. The indwelling catheter used for drainage was kept for 7 to 14 days postoperatively. Intravenous antibiotics were administered for 3 days, followed by oral antibiotics for an additional 3 to 5 days. Clinical data were collected from medical records, including the patients’ demographics (age and body mass index (BMI) at the time of UCF repair, history of low birth weight and prematurity). Details of the initial urethroplasty were also recorded, such as urethral defect length, operative approaches (preservation vs. transection of the urethral plate), the urethral covering during HR (Buck’s fascia vs. dartos or tunica vaginalis flap), the interval between HR and the presentation of UCFs, meatal stenosis (yes vs. no), size and number of UCFs (single vs. multiple), and location of UCF (coronal vs. non-coronal), the interval between urethroplasty and UCF repair. For the patients with multiple UCFs and recurrence, the location was determined by the recurrent ones. All patients were followed up in the outpatient clinic at our hospital at 2 weeks and 3 months after UCF repair, and then twice a year thereafter to monitor for complications. The study endpoints were UCF recurrence and the need for additional penile surgeries. Statistical analysis Statistical analysis was conducted using IBM Corp.'s SPSS 25.0 and GraphPad Prism 9.0.Continuous variables were expressed as the mean ± standard deviation, while skewed distributions were presented as the interquartile range. Univariate differences between outcomes were analyzed using the Chi-squared test, Student t- test and Mann-Whitney U -test. Parameters with P < 0.1 in univariate analyses were entered into a binary logistic regression to identify the risk factors for UCF recurrence. Comparisons were considered statistically significant at P < 0.05. Results A total of 218 patients underwent UCF repair after HR in our department from January 2013 to December 2022. Among them, 7 patients were lost to follow-up, and 7 patients presented with urethral stricture or urethral diverticulum. Additionally, 68 patients required redo-urethroplasty, including 47 who underwent TIP (with preputial inlay graft in 6 cases), 12 who underwent Mathieu procedure, 6 who underwent Thiersch-Duplay technique, 1 who underwent Onlay island flap repair, and 2 who underwent two-stage repair with buccal mucosa graft. Ultimately, 136 patients with a median age of 52 months (range: 20 to 204 months) met the inclusion criteria and were included in this study. After a median follow-up of 36.2 months (range: 11 to 120 months), 105 patients were successfully treated (group 1), while 31 patients experienced UCF recurrence (group 2). The success rate of primary UCF repair was 77.2% (105/136). (Table 1 ) In univariable analysis, no statistically significant differences were found between the two groups regarding the history of low birth weight and prematurity ( x 2 = 2.520, P = 0.112 and x 2 = 0.216, P = 0.642), age at UCF repair ( Z = 0.755, P = 0.450), age at urethroplasty ( Z = 0.649, P = 0.517), length of neourethra ( Z = 0.074, P = 0.941), interval between HR and UCF repair ( Z = 0.962, P = 0.337), operative approaches ( x 2 = 0.915, P = 0.339), meatal stenosis ( x 2 = 2.183, P = 0.140). However, the size, location, and number of UCFs ( x 2 = 8.033, P = 0.018, x 2 = 10.389, P = 0.002, and x 2 = 9.289, P = 0.002), interval between HR and UCF presentation ( Z = 2.540, P = 0.013), and urethral covering during HR ( x 2 = 8.093, P = 0.004) were considered potential risk factors (Table 2 ). The results of the binary logistic regression equation showed that UCF with a diameter exceed 4mm (OR 6.968, 95% CI 1.522–31.898, P = 0.012), multiple UCFs ( OR 4.017, 95% CI 1.284–12.571, P = 0.017), coronal UCF ( OR 2.964, 95% CI 1.142–7.695, P = 0.026), and urethral covering with dartos/ dartos or tunica vaginalis flap during HR ( OR 2.631, 95% CI 1.015–6.819, P = 0.047) were statistically significant and correlated with the risk of UCF recurrence. However, UCF with diameters ranging from 2 to less than 4mm ( OR 2.129, 95% CI 0.698–6.495, P = 0.184) and the interval between HR and UCF presentation ( OR 0.997, 95% CI 0.986–1.008, P = 0.606) did not emerge as statistically significant factors (Table 3 ). Discussion Various improvements in the details of UCF repair, including Y-V advanced skin flap pasty, tunica vaginalis flap and longitudinal relaxing incision, all aim to achieve tension-free closure, multilayer covering with hyper-vascularized tissue, and correction of distal obstruction [ 7 – 9 ]. However, UCF recurrence remains a challenge, and it is difficult to designate any technique as ideal or perfect. Numerous factors, such as UCF characteristics, meatal stenosis, local tissue conditions surrounding the fistula, details of the initial urethroplasty, and the surgical skills of the surgeon, are believed to be associated with the development of UCF recurrence [ 4 , 5 ]. The incidence of UCF recurrence has been reported to be approximately 20% in previous studies [ 2 – 6 ]. Consistent with these findings, the UCF recurrence rate in our study was 22.8% (31/136). However, it is noteworthy noting that Snodgrass reported in a prospective study that the fistula recurrence rate was only 5% (2/37) which may be attributed to his excellent surgical skills [ 10 ]. Preoperative general health status and a history of suboptimal health may induce immunosuppression and increase morbidity after surgery. Fortunately, in our study, BMI at fistulectomy, history of low birth weight and prematurity did not increase the risk of UCF recurrence. Similar to findings by Dokter, who reported that common preoperative illness not severe enough to postpone surgery appeared to have a protective effect after hypospadias repair [ 11 ], suggesting that the success rate of UCF repair might be more dependent on the condition of the penis itself. The condition during primary HR, such as defect in urethra length and the approach of urethroplasty, might affect the success rate of UCF repair, as different complication rates arise from different types of urethroplasty [ 5 ]. In our previous study, we observed that preserving the urethral plate or transecting it resulted in different UCF rates: 6.2% (59/949) and 3.2% (14/437), respectively [ 12 ]. However, in this further study, we found that preserving the urethral plate or not, as well as the length of the neourethra, did not affect the outcome of UCF repair. It may indicate that once the neourethra has survived, local lesions of the neourethra do not depend on the initial surgery but rather on the characteristics of the UCF itself. Six months is recognized as the time required for skin vascularization and scar tissue softening. Therefore, all UCF repairs were performed at least 6 months after urethroplasty. Han reported that this interval was not a risk factor for failed UCF repair after transvers preputial island flap urethroplasty, which was consistent with our results ( P = 0.037) [ 4 ]. Based on this, we conclude that 6 months is long enough for UCF repair, regardless of the approach adopted for primary urethroplasty. Although almost all UCFs occurred around one month after primary urethroplasty and were diagnosed within the first year after surgery, delayed presentation of UCFs was not rare [ 13 ]. The longest time to presentation of delayed UCF was 15.2 years, as reported by Johnston et al. [ 14 ]. In our study, 2% (3/136) of patients presented more than 1 year after HR. It is generally believed that delayed presentation of UCF after HR may be due to chronic urethral changes with age leading to unobvious obstruction or infection, while early presentation of UCF is mostly caused by ischemia, overlying lines, etc. To understand the influence of time on the outcome of UCF repair, we included patients’ age at UCF repair and the interval between HR and UCF presentation in univariate analysis. The results showed that the interval between HR and UCF presentation differed significantly between the success and recurrence groups. However, in the multivariate analysis, this interval was not a risk factor related to the recurrence of UCFs ( P = 0.606). Therefore, we believe that late presentation and age at UCF repair would not affect the outcome of UCF repair. Concomitant meatal stenosis is another risk factor for causing UCF, primarily through a mechanism of elevated pressures in the neourethra. Increased urethral pressure may lead to UCF recurrence. However, defining UCFs associated with meatal stenosis is challenging. Therefore, we combined the symptomatic presentation of patients with the intraoperative evaluation of the surgeon to diagnose meatal stenosis. Furthermore, a meatus that may be sufficient for a younger child may not suffice later in life. In this study, five patients were diagnosed with meatal stenosis, and the results mirrored previous reports indicating that once the meatoplasty was conducted simultaneously, it was not a risk factor of UCF recurrence [ 15 ]. Coronal fistula has long been regarded as a challenging issue in clinical management due to the lack of surrounding tissues. Although the location of the UCF was not consistently identified as a risk factor for failed UCF repair in some research [ 5 , 16 ], we still consider it crucial to investigate in this study. Upon analyzing the data, we observed that the occurrence rate of coronal UCF was significantly higher than that of non-coronal UCF in both the univariate and multivariate analyses. Size and number were identified as the other two critical risk factors. The size of UCF was generally accepted as an independent risk factor correlated with failed UCF repair. The previously reported cut-off value of UCF diameter was 2mm [ 4 , 10 , 17 ]. Fan and colleagues concluded that classical fistulectomy was appropriated for coronal UCF with diameter < 2mm and 2- 4mm, TIP or Mathieu urethroplasty was recommended. Classical fistulectomy applies to non-coronal UCF of all sizes [ 17 ]. Referencing this literature, we categorized the UCFs into three distinct groups according to the size of their diameters for analysis. The results of binary regression analysis revealed a significant difference among the groups. Specifically, UCFs with a diameter exceeding 4mm exhibited a higher recurrence rate compared to those with a diameter less than 2mm.These findings underscore the undeniable significance of the intrinsic characteristics of UCF in the success of UCF repair procedure. Buck’s fascia was used as an integral covering in various urethroplasty for several years, with a certain effect on reducing the incidence of UCF. A multicenter retrospective study, including our institution, showed that out of 1386 patients who underwent one-stage urethroplasty, the incidence of UCF was 5.2% (73/1368), much lower than in other studies [ 12 ]. Successful repair of UCF depends on the inherent vitality of the neourethral tissue and the health of the local environment surrounding the fistula. Surgical proficiency and techniques employed in urethroplasty are also recognized as significant factors that could potentially influence the outcome [ 4 ]. Considering that 70 patients underwent primary urethroplasty combined with Buck’s fascia coverage, we added this factor in this study. As anticipated, both univariate and binary regression analyses corroborated that this factor is significantly associated with a reduced risk of UCF recurrence. We speculate that with the use of Buck’s fascia coverage during HR not only restores the continuity of the urethral spongiosum but also optimizes the stratification of urethral coverage to more closely resemble the normal anatomical structure. Furthermore, during the process of UCF repair, there was a more sufficient coverage of the fistula orifice with the dartos fascia contributes to a more robust healing process. Limitation The present study has several limitations that warrant acknowledgment. First, the stringent exclusion criteria may have resulted in the exclusion of potentially valuable cases, including patients with associated glans dehiscence. Second, we did not employ uroflowmetry, a measure that could have provided insights into the degree of urethral patency post repair. Third, the potential impact of postoperative infection on outcomes was not addressed within this study. Additionally, while our follow-up period was sufficient to detect most UCF recurrences, Hadley's report suggests that a small subset of patients (only 5.5%) with recurrent UCF present symptoms more than 1 year post repair[ 18 ]. This suggests that there is a possibility that some cases of late-presenting recurrent UCF were not captured in our study. Consequently, a long-term follow-up study is recommended to provide a more comprehensive understanding of late recurrences. Conclusion Considering the factors outlined above, the success of UCF repair hinges largely on the characteristics of UCF itself. UCF repair is more prone to failure if the size of UCF exceeds 4mm, if it is located at the coronary sulcus, or if there were multiple UCFs present. To mitigate the risk of UCF following HR or the recurrence of UCF after its repair, Buck’s fascia should be considered the primary option for urethral coverage during the process of HR, when feasible. Declarations Data Availability declaration The data that support the findings of this study are available from the corresponding author, upon reasonable request. Conflict of interest The authors declare that they have no conflict of interest. Financial interests The authors have no relevant financial or non-financial interests to disclose. Funding This study was funded by Anhui Province Higher Education Institutions Scientific Research Projects (2023AH050665). Ethics approval Ethical approval to conduct this study was issued by the Ethics committee of Anhui Provincial Children’s Hospital in view of the retrospective nature of the study (IRB number: EYLL-2023-021). Authors’ contribution All authors contributed to this study’s conception and design. Data collection and analysis were performed by Ye Zhang, Qihang Sun and Kaiping Zhang. All operations were conducted by Ye Zhang, Yin Zhang, Jiabin Jiang and Min Chao. The first draft of the manuscript was written by Ye Zhang. All authors read and revised the previous manuscript and approved the final manuscript. Informed consent Written informed consent for publication of their clinical details and/or clinical images was obtained from the patient/parent/guardian/ relative of the patient. References Hardwicke JT, Bechar JA, Hodson J, Osmani O, Park AJ. Fistula after single-stage primary hypospadias repair - A systematic review of the literature. J Plast Reconstr Aesthet Surg. 2015 Dec;68(12):1647-55. doi: 10.1016/j.bjps.2015.07.024. Sunay M, Dadali M, Karabulut A, et al. Our 23-year experience in urethrocutaneous fistulas developing after hypospadias surgery. Urology. 2007;69(2):366–368. Choudhury P, Saroya KK, Jain V, Yadav DK, Dhua AK, Anand S, Mawar S, Verma V, Kapahtia S, Acharya SK, Shah R, Bajpai M, Goel P. 'Waterproofing layers' for urethrocutaneous fistula repair after hypospadias surgery: evidence synthesis with systematic review and meta-analysis. Pediatr Surg Int. 2023 Apr 3;39(1):165. doi: 10.1007/s00383-023-05405-1. 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 Feb;50(2):191-195. doi: 10.1007/s11255-017-1773-x. Abdullaev Z, Agzamkhodjaev S, Chung JM, Lee SD. Risk factors for fistula recurrence after urethrocutaneous fistulectomy in children with hypospadias. Turk J Urol. 2021 May;47(3):237-241. doi: 10.5152/tud.2020.20323. Feng J, Yang Z, Tang Y, Chen W, Zhao MX, Ma N, Wang WX, Xu LS, Li YQ. Risk Factors for Urethrocutaneous Fistula Repair After Hypospadias Surgery: A Retrospective Study. Ann Plast Surg. 2017 Dec;79(6):e41-e44. doi: 10.1097/SAP.0000000000001128. 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 Mar;84(3):317-321. doi: 10.1097/SAP.0000000000002056. 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Tables Table 1 Baseline Patient Characteristics Characteristics Total patients, n 136 UCF repair success, n (%) 105 (77.2%) Age (month), median (range) 52 (20–204) Follow-up time (month), median (range) 36.2 (11–120) Type of HR preservation of the urethral plate (n) TIP (DIG) 46 OIF 14 transection of the urethral plate (n) TPIF 53 Koyanagi 3 Staged repair 20 HR: hypospadias repair; TIPU: tubularized incised plate urethroplasty; DIF: dorsal inlay graft; OIF: onlay island flap; TPIF: transverse preputial island flap; Table 2 Univariate analysis of variables related to UCF recurrence. Variable Total (n = 136) UCF cured (n = 105) UCF recurrence (n = 31) Statistic P BMI, M (Q₁, Q₃) 15.50 (14.54, 16.51) 15.50 (14.58, 16.54) 15.57 (14.41, 16.45) Z = 0.018 0.986 Age at UCF repair, M (Q₁, Q₃) 52.00 (36.00, 79.75) 52.00 (35.00, 82.00) 55.00 (42.50, 75.50) Z = 0.755 0.450 Age at urethroplasty, M (Q₁, Q₃) 35.00 (19.00, 60.00) 34.00 (19.00, 61.00) 41.00 (25.50, 53.50) Z = 0.649 0.517 Length of neourethra, M (Q₁, Q₃) 3.00 (2.00, 3.50) 3.00 (2.00, 3.50) 3.00 (2.00, 4.00) Z = 0.074 0.941 Interval time of urethroplasty and UCF occurrence, M (Q₁, Q₃) 21.00 (14.00, 28.00) 21.00 (14.00, 28.00) 14.00 (10.00, 28.00) Z = 2.540 0.013* Size of UCF, n (%) χ² =8.033 0.018* < 2mm 47 (34.56%) 41(39.05%) 6 (19.35%) ≧ 2mm, <4mm 75 (55.15%) 57 (54.28%) 18 (58.06%) ≧ 4mm 14 (10.29%) 7 (6.67%) 7 (22.58%) Interval time of UCF repair and urethroplasty, M (Q₁, Q₃) 13.00 (10.75, 20.00) 13.00 (10.00, 19.00) 14.00 (12.00, 24.00) Z = 0.962 0.337 Number of UCFs, n (%) One 117 (86.2%) 96 (91.43%) 21 (67.74%) χ² =9.289 0.002* multiple 19 (3.9%) 9 (8.57%) 10 (32.26%) History of prematurity, n (%) No 122 (89.71%) 93 (88.57%) 29 (93.55%) χ² =0.216 0.642 Yes 14 (10.29%) 12 (11.43%) 2 (6.45%) History of low birth weight, n (%) No 104 (76.47%) 77 (73.33%) 27 (87.10%) χ² =2.520 0.112 Yes 32 (23.53%) 28 (26.67%) 4 (12.90%) Location of UCF, n (%) Non-Coronal 86 (63.24%) 74 (70.48%) 12 (38.71%) χ² =10.389 0.002* Coronal 50 (36.76%) 31 (29.52%) 19 (61.29%) Operative approaches during HR, n (%) Preserve the urethral plate 60 (44.12%) 44 (41.90%) 16 (51.61%) χ² =0.915 0.339 Transect the urethral plate 76 (55.88%) 61 (58.10%) 15 (48.39%) Urethral recover during HR, n (%) Buck’s fascia 70 (51.47%) 61 (58.10%) 9 (29.03%) χ² =8.093 0.004* dartos fascia/ tunica vaginalis flap 66 (48.53%) 44 (41.90%) 22 (70.97%) Meatal stenosis, n (%) No 131 (96.32%) 103 (98.10%) 28 (90.32%) χ² =2.183 0.140 Yes 5 (3.68%) 2 (1.90%) 3 (9.68%) * P < 0.1 were considered statistically significant; HR hypospadias repair Table 3 Binary logistic regression analysis of variables related to UCF recurrence. Variables Beta S.E. Wald Df P OR (95% CI) Location of UCFs Non-coronal# 1.087 0.487 4.984 1 0.026* 2.964 (1.142–7.695) coronal Size of UCFs < 2mm# 6.257 2 0.044* ≧ 2mm, <4mm 0.755 0.569 1.762 1 0.184 2.129 (0.698–6.495) ≧ 4mm 1.941 0.776 6.257 1 0.012* 6.968 (1.522–31.898) Number of UCFs One# 1.391 0.582 5.707 1 0.017* 4.017 (1.284–12.571) Multiple Urethral covering during HR Buck’s fascia# 0.967 0.486 3.961 1 0.047* 2.631 (1.015–6.819) dartos fascia/tunica vaginalis flap Interval time of urethroplasty and UCF occurrence 0.015 0.016 0.892 1 0.345 1.015 (0.984–1.048) *P < 0.05 were considered statistically significant #control group UCF: urethrocutaneous fistula; HR: hypospadias repair Additional Declarations No competing interests reported. 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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-4658990","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":325291335,"identity":"d3d86bb9-09eb-4c7d-bc4f-4246b66198bc","order_by":0,"name":"Ye Zhang","email":"","orcid":"","institution":"Anhui Provincial Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ye","middleName":"","lastName":"Zhang","suffix":""},{"id":325291336,"identity":"697457f8-73c6-4727-92d6-f6b2c32a605c","order_by":1,"name":"Qihang Sun","email":"","orcid":"","institution":"Anhui Provincial Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Qihang","middleName":"","lastName":"Sun","suffix":""},{"id":325291337,"identity":"e95c631d-8907-4873-8c33-0bad3ae6134c","order_by":2,"name":"Kaiping Zhang","email":"","orcid":"","institution":"Anhui Provincial Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kaiping","middleName":"","lastName":"Zhang","suffix":""},{"id":325291338,"identity":"894394b7-8021-431a-a549-f90662d1d966","order_by":3,"name":"Yin Zhang","email":"","orcid":"","institution":"Anhui Provincial Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yin","middleName":"","lastName":"Zhang","suffix":""},{"id":325291339,"identity":"133842f1-ee53-4ed6-80ab-1d184d653dc3","order_by":4,"name":"Jiabin Jiang","email":"","orcid":"","institution":"Anhui Provincial Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jiabin","middleName":"","lastName":"Jiang","suffix":""},{"id":325291340,"identity":"b50f92d4-ea1c-4dea-9e18-dbf7e2ac25b8","order_by":5,"name":"Min Chao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIiWNgGAWjYDACCRBhwCDHxt7Y+ADITCBaizE/z+HDBlAtjA2EtTAwJM6ckZYmQZQW/tnNDx/dKLjDuOFAjlk1T4VdHoN08/EHeC25c8zYOMfgGbPBgTNmt3nOJBczyBxLxGuLgUSCmXSOwWE2g4M9Zrd525gTGyRyDAloSf8G0sIDRGbFvP/qgVryPxLQkgO2RUKyjS2NmbfhMMgW/N6XuJFTDPTLYQN+HubDknOOHU9sk0gznIFPC/+M9I2Pc/4crm+Tf9j44U1NdWK/RPKDD/i0oAAmHiDBRrRyEGD8QZLyUTAKRsEoGCkAAOsUTSpRFBD+AAAAAElFTkSuQmCC","orcid":"","institution":"Anhui Provincial Children’s Hospital","correspondingAuthor":true,"prefix":"","firstName":"Min","middleName":"","lastName":"Chao","suffix":""}],"badges":[],"createdAt":"2024-06-29 11:01:55","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4658990/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4658990/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":75455941,"identity":"dd88f331-cad5-425e-9d49-cbb3af193e2e","added_by":"auto","created_at":"2025-02-04 20:16:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":642419,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4658990/v1/ee185cdf-b2ec-4ac0-bb36-d754ff07b67f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Predictors of Treatment Failure in Urethrocutaneous Fistula Repair for Hypospadias: A Retrospective Analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUrethrocutaneous fistula (UCF) represents the most prevalent complication post-hypospadias repair (HR), with incidence rates varying widely from 0\u0026ndash;45% across the published literature [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The presence of UCF is frequently employed as a measure of HR success. Numerous surgical techniques, such as simple classical closure, double ligation, and V-Y advanced skin flap, have been extensively documented for managing UCF based on its unique characteristics. The core tenets of UCF repair encompass tension-free closure, multilayer covering, appropriate suture selection, and correction of any associated urethral stricture. However, UCF recurs approximately 20% of the time [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. A recent meta-analysis of 2886 patients who underwent UCF repair found that 539 experienced recurrences, with success rates for different approaches ranging from 54.5\u0026ndash;100% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Various risk factors for recurrent UCF have been explored, apart from the characteristic of UCF itself, such as the type of hypospadias, the length of urethral defect, and urethral operation history [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Drawing from our clinical experience, the efficacy of UCF repair appears to hinge primarily on the UCF\u0026rsquo;s intrinsic nature rather than extraneous elements. Given that Buck\u0026rsquo;s fascia, utilized as a critical coverage in HR, has effectively reduced the incidence of UCF in our institution, we hypothesize that is may also exerts a positive effect on post UCF repair outcomes. To validate this hypothesis, we have conducted a retrospective evaluation of a decade-long UCF repair practice to delineate predictors of UCF recurrence.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003e This retrospective study was conducted in accordance with the Declaration of Helsinki and received ethical approval from the Institutional ethical committee of Anhui Children\u0026rsquo;s Hospital (IRB number: EYLL-2023-021). We revised the clinical data of patients who underwent UCF repair after HR and were admitted to our institution between January 2013 and December 2022. Missing information was obtained through telephone interviews with informed consent from their guardians. Concomitant meatal stenosis was defined by symptoms such as a narrow urinary stream or dysuria, and the diagnosis was confirmed through intraoperative evaluation of the meatal size. We applied the following exclusion criteria: (1) patients with other urethral complications, such as urethral stricture or urethral diverticulum, since correction of these complications simultaneously may require redo-urethroplasty; (2) patients with coronal UCF combined with glans dehiscence who underwent redo-urethroplasty such as TIP (tubularized incised plate) urethroplasty or Mathieu urethroplasty; (3) patients with follow-up periods of less than 6 months since their last operations; (4) patients with incomplete clinical information.\u003c/p\u003e \u003cp\u003eAll operations were performed under general anesthesia combined with a caudal block at least six months after HR. Before UCF repair, indigo carmine blue solution was injected into the meatus, meanwhile, a tourniquet was applied around the base of the penis to occlude the urethra, preventing the omission of small UCFs. The diameter of the UCF was measured using a ruler. The epithelialized tract to the urethra was excised, and the urothelial edges of UCF were closed in a subepithelial fashion. All UCFs were overlaid with vascularized tissue, such as a local dartos flap. Skin closure was performed using a Y-V advanced skin flap to avoid overlapping sutures. In cases with meatal stenosis, meatoplasty was preformed simultaneously. The indwelling catheter used for drainage was kept for 7 to 14 days postoperatively. Intravenous antibiotics were administered for 3 days, followed by oral antibiotics for an additional 3 to 5 days.\u003c/p\u003e \u003cp\u003eClinical data were collected from medical records, including the patients\u0026rsquo; demographics (age and body mass index (BMI) at the time of UCF repair, history of low birth weight and prematurity). Details of the initial urethroplasty were also recorded, such as urethral defect length, operative approaches (preservation vs. transection of the urethral plate), the urethral covering during HR (Buck\u0026rsquo;s fascia vs. dartos or tunica vaginalis flap), the interval between HR and the presentation of UCFs, meatal stenosis (yes vs. no), size and number of UCFs (single vs. multiple), and location of UCF (coronal vs. non-coronal), the interval between urethroplasty and UCF repair. For the patients with multiple UCFs and recurrence, the location was determined by the recurrent ones.\u003c/p\u003e \u003cp\u003e All patients were followed up in the outpatient clinic at our hospital at 2 weeks and 3 months after UCF repair, and then twice a year thereafter to monitor for complications. The study endpoints were UCF recurrence and the need for additional penile surgeries.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was conducted using IBM Corp.'s SPSS 25.0 and GraphPad Prism 9.0.Continuous variables were expressed as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, while skewed distributions were presented as the interquartile range. Univariate differences between outcomes were analyzed using the Chi-squared test, Student \u003cem\u003et-\u003c/em\u003etest and Mann-Whitney \u003cem\u003eU\u003c/em\u003e-test. Parameters with P\u0026thinsp;\u0026lt;\u0026thinsp;0.1 in univariate analyses were entered into a binary logistic regression to identify the risk factors for UCF recurrence. Comparisons were considered statistically significant at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 218 patients underwent UCF repair after HR in our department from January 2013 to December 2022. Among them, 7 patients were lost to follow-up, and 7 patients presented with urethral stricture or urethral diverticulum. Additionally, 68 patients required redo-urethroplasty, including 47 who underwent TIP (with preputial inlay graft in 6 cases), 12 who underwent Mathieu procedure, 6 who underwent Thiersch-Duplay technique, 1 who underwent Onlay island flap repair, and 2 who underwent two-stage repair with buccal mucosa graft. Ultimately, 136 patients with a median age of 52 months (range: 20 to 204 months) met the inclusion criteria and were included in this study. After a median follow-up of 36.2 months (range: 11 to 120 months), 105 patients were successfully treated (group 1), while 31 patients experienced UCF recurrence (group 2). The success rate of primary UCF repair was 77.2% (105/136). (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn univariable analysis, no statistically significant differences were found between the two groups regarding the history of low birth weight and prematurity (\u003cem\u003ex\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;2.520, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.112 and \u003cem\u003ex\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.216, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.642), age at UCF repair (\u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.755, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.450), age at urethroplasty (\u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.649, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.517), length of neourethra (\u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.074, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.941), interval between HR and UCF repair (\u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.962, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.337), operative approaches (\u003cem\u003ex\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.915, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.339), meatal stenosis (\u003cem\u003ex\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;2.183, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.140). However, the size, location, and number of UCFs (\u003cem\u003ex\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;8.033, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.018, \u003cem\u003ex\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;10.389, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002, and \u003cem\u003ex\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;9.289, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002), interval between HR and UCF presentation (\u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.540, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.013), and urethral covering during HR (\u003cem\u003ex\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;8.093, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004) were considered potential risk factors (Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The results of the binary logistic regression equation showed that UCF with a diameter exceed 4mm (OR 6.968, 95% CI 1.522\u0026ndash;31.898, P\u0026thinsp;=\u0026thinsp;0.012), multiple UCFs (\u003cem\u003eOR\u003c/em\u003e 4.017, \u003cem\u003e95% CI\u003c/em\u003e 1.284\u0026ndash;12.571, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.017), coronal UCF (\u003cem\u003eOR\u003c/em\u003e 2.964, \u003cem\u003e95% CI\u003c/em\u003e 1.142\u0026ndash;7.695, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.026), and urethral covering with dartos/ dartos or tunica vaginalis flap during HR (\u003cem\u003eOR\u003c/em\u003e 2.631, \u003cem\u003e95% CI\u003c/em\u003e 1.015\u0026ndash;6.819, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.047) were statistically significant and correlated with the risk of UCF recurrence. However, UCF with diameters ranging from 2 to less than 4mm (\u003cem\u003eOR\u003c/em\u003e 2.129, \u003cem\u003e95% CI\u003c/em\u003e 0.698\u0026ndash;6.495, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.184) and the interval between HR and UCF presentation (\u003cem\u003eOR\u003c/em\u003e 0.997, \u003cem\u003e95% CI\u003c/em\u003e 0.986\u0026ndash;1.008, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.606) did not emerge as statistically significant factors (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eVarious improvements in the details of UCF repair, including Y-V advanced skin flap pasty, tunica vaginalis flap and longitudinal relaxing incision, all aim to achieve tension-free closure, multilayer covering with hyper-vascularized tissue, and correction of distal obstruction [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, UCF recurrence remains a challenge, and it is difficult to designate any technique as ideal or perfect. Numerous factors, such as UCF characteristics, meatal stenosis, local tissue conditions surrounding the fistula, details of the initial urethroplasty, and the surgical skills of the surgeon, are believed to be associated with the development of UCF recurrence [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The incidence of UCF recurrence has been reported to be approximately 20% in previous studies [\u003cspan additionalcitationids=\"CR3 CR4 CR5\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Consistent with these findings, the UCF recurrence rate in our study was 22.8% (31/136). However, it is noteworthy noting that Snodgrass reported in a prospective study that the fistula recurrence rate was only 5% (2/37) which may be attributed to his excellent surgical skills [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePreoperative general health status and a history of suboptimal health may induce immunosuppression and increase morbidity after surgery. Fortunately, in our study, BMI at fistulectomy, history of low birth weight and prematurity did not increase the risk of UCF recurrence. Similar to findings by Dokter, who reported that common preoperative illness not severe enough to postpone surgery appeared to have a protective effect after hypospadias repair [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], suggesting that the success rate of UCF repair might be more dependent on the condition of the penis itself.\u003c/p\u003e \u003cp\u003eThe condition during primary HR, such as defect in urethra length and the approach of urethroplasty, might affect the success rate of UCF repair, as different complication rates arise from different types of urethroplasty [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In our previous study, we observed that preserving the urethral plate or transecting it resulted in different UCF rates: 6.2% (59/949) and 3.2% (14/437), respectively [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, in this further study, we found that preserving the urethral plate or not, as well as the length of the neourethra, did not affect the outcome of UCF repair. It may indicate that once the neourethra has survived, local lesions of the neourethra do not depend on the initial surgery but rather on the characteristics of the UCF itself.\u003c/p\u003e \u003cp\u003eSix months is recognized as the time required for skin vascularization and scar tissue softening. Therefore, all UCF repairs were performed at least 6 months after urethroplasty. Han reported that this interval was not a risk factor for failed UCF repair after transvers preputial island flap urethroplasty, which was consistent with our results (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.037) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Based on this, we conclude that 6 months is long enough for UCF repair, regardless of the approach adopted for primary urethroplasty. Although almost all UCFs occurred around one month after primary urethroplasty and were diagnosed within the first year after surgery, delayed presentation of UCFs was not rare [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The longest time to presentation of delayed UCF was 15.2 years, as reported by Johnston et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In our study, 2% (3/136) of patients presented more than 1 year after HR. It is generally believed that delayed presentation of UCF after HR may be due to chronic urethral changes with age leading to unobvious obstruction or infection, while early presentation of UCF is mostly caused by ischemia, overlying lines, etc. To understand the influence of time on the outcome of UCF repair, we included patients\u0026rsquo; age at UCF repair and the interval between HR and UCF presentation in univariate analysis. The results showed that the interval between HR and UCF presentation differed significantly between the success and recurrence groups. However, in the multivariate analysis, this interval was not a risk factor related to the recurrence of UCFs (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.606). Therefore, we believe that late presentation and age at UCF repair would not affect the outcome of UCF repair.\u003c/p\u003e \u003cp\u003eConcomitant meatal stenosis is another risk factor for causing UCF, primarily through a mechanism of elevated pressures in the neourethra. Increased urethral pressure may lead to UCF recurrence. However, defining UCFs associated with meatal stenosis is challenging. Therefore, we combined the symptomatic presentation of patients with the intraoperative evaluation of the surgeon to diagnose meatal stenosis. Furthermore, a meatus that may be sufficient for a younger child may not suffice later in life. In this study, five patients were diagnosed with meatal stenosis, and the results mirrored previous reports indicating that once the meatoplasty was conducted simultaneously, it was not a risk factor of UCF recurrence [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCoronal fistula has long been regarded as a challenging issue in clinical management due to the lack of surrounding tissues. Although the location of the UCF was not consistently identified as a risk factor for failed UCF repair in some research [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], we still consider it crucial to investigate in this study. Upon analyzing the data, we observed that the occurrence rate of coronal UCF was significantly higher than that of non-coronal UCF in both the univariate and multivariate analyses. Size and number were identified as the other two critical risk factors. The size of UCF was generally accepted as an independent risk factor correlated with failed UCF repair. The previously reported cut-off value of UCF diameter was 2mm [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Fan and colleagues concluded that classical fistulectomy was appropriated for coronal UCF with diameter\u0026thinsp;\u0026lt;\u0026thinsp;2mm and 2-\u0026lt;4mm. For patients with coronal UCF combined with glans dehiscence or a coronal UCF with a diameter\u0026thinsp;\u0026gt;\u0026thinsp;4mm, TIP or Mathieu urethroplasty was recommended. Classical fistulectomy applies to non-coronal UCF of all sizes [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Referencing this literature, we categorized the UCFs into three distinct groups according to the size of their diameters for analysis. The results of binary regression analysis revealed a significant difference among the groups. Specifically, UCFs with a diameter exceeding 4mm exhibited a higher recurrence rate compared to those with a diameter less than 2mm.These findings underscore the undeniable significance of the intrinsic characteristics of UCF in the success of UCF repair procedure.\u003c/p\u003e \u003cp\u003eBuck\u0026rsquo;s fascia was used as an integral covering in various urethroplasty for several years, with a certain effect on reducing the incidence of UCF. A multicenter retrospective study, including our institution, showed that out of 1386 patients who underwent one-stage urethroplasty, the incidence of UCF was 5.2% (73/1368), much lower than in other studies [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Successful repair of UCF depends on the inherent vitality of the neourethral tissue and the health of the local environment surrounding the fistula. Surgical proficiency and techniques employed in urethroplasty are also recognized as significant factors that could potentially influence the outcome [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Considering that 70 patients underwent primary urethroplasty combined with Buck\u0026rsquo;s fascia coverage, we added this factor in this study. As anticipated, both univariate and binary regression analyses corroborated that this factor is significantly associated with a reduced risk of UCF recurrence. We speculate that with the use of Buck\u0026rsquo;s fascia coverage during HR not only restores the continuity of the urethral spongiosum but also optimizes the stratification of urethral coverage to more closely resemble the normal anatomical structure. Furthermore, during the process of UCF repair, there was a more sufficient coverage of the fistula orifice with the dartos fascia contributes to a more robust healing process.\u003c/p\u003e\n\u003ch3\u003eLimitation\u003c/h3\u003e\n\u003cp\u003eThe present study has several limitations that warrant acknowledgment. First, the stringent exclusion criteria may have resulted in the exclusion of potentially valuable cases, including patients with associated glans dehiscence. Second, we did not employ uroflowmetry, a measure that could have provided insights into the degree of urethral patency post repair. Third, the potential impact of postoperative infection on outcomes was not addressed within this study. Additionally, while our follow-up period was sufficient to detect most UCF recurrences, Hadley's report suggests that a small subset of patients (only 5.5%) with recurrent UCF present symptoms more than 1 year post repair[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This suggests that there is a possibility that some cases of late-presenting recurrent UCF were not captured in our study. Consequently, a long-term follow-up study is recommended to provide a more comprehensive understanding of late recurrences.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eConsidering the factors outlined above, the success of UCF repair hinges largely on the characteristics of UCF itself. UCF repair is more prone to failure if the size of UCF exceeds 4mm, if it is located at the coronary sulcus, or if there were multiple UCFs present. To mitigate the risk of UCF following HR or the recurrence of UCF after its repair, Buck\u0026rsquo;s fascia should be considered the primary option for urethral coverage during the process of HR, when feasible.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author, upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by Anhui Province Higher Education Institutions Scientific Research Projects (2023AH050665).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval to conduct this study was issued by the Ethics committee of Anhui Provincial Children’s Hospital in view of the retrospective nature of the study (IRB number: EYLL-2023-021).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to this study’s conception and design. Data collection and analysis were performed by Ye Zhang, Qihang Sun and Kaiping Zhang. All operations were conducted by Ye Zhang, Yin Zhang, Jiabin Jiang and Min Chao. The first draft of the manuscript was written by Ye Zhang. All authors read and revised the previous manuscript and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of their clinical details and/or clinical images was obtained from the patient/parent/guardian/ relative of the patient.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHardwicke JT, Bechar JA, Hodson J, Osmani O, Park AJ. Fistula after single-stage primary hypospadias repair - A systematic review of the literature. J Plast Reconstr Aesthet Surg. 2015 Dec;68(12):1647-55. doi: 10.1016/j.bjps.2015.07.024.\u003c/li\u003e\n\u003cli\u003eSunay M, Dadali M, Karabulut A, et al. Our 23-year experience in urethrocutaneous fistulas developing after hypospadias surgery. Urology. 2007;69(2):366\u0026ndash;368.\u003c/li\u003e\n\u003cli\u003eChoudhury P, Saroya KK, Jain V, Yadav DK, Dhua AK, Anand S, Mawar S, Verma V, Kapahtia S, Acharya SK, Shah R, Bajpai M, Goel P. \u0026apos;Waterproofing layers\u0026apos; for urethrocutaneous fistula repair after hypospadias surgery: evidence synthesis with systematic review and meta-analysis. Pediatr Surg Int. 2023 Apr 3;39(1):165. doi: 10.1007/s00383-023-05405-1.\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 Feb;50(2):191-195. doi: 10.1007/s11255-017-1773-x.\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. Turk J Urol. 2021 May;47(3):237-241. doi: 10.5152/tud.2020.20323. \u003c/li\u003e\n\u003cli\u003eFeng J, Yang Z, Tang Y, Chen W, Zhao MX, Ma N, Wang WX, Xu LS, Li YQ. Risk Factors for Urethrocutaneous Fistula Repair After Hypospadias Surgery: A Retrospective Study. Ann Plast Surg. 2017 Dec;79(6):e41-e44. doi: 10.1097/SAP.0000000000001128.\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 Mar;84(3):317-321. doi: 10.1097/SAP.0000000000002056.\u003c/li\u003e\n\u003cli\u003ePescheloche P, Parmentier B, Hor T, Chamond O, Chabaud M, Irtan S, Audry G. Tunica vaginalis flap for urethrocutaneous fistula repair after proximal and mid-shaft hypospadias surgery: A 12-year experience. J Pediatr Urol. 2018 Oct;14(5): 421.e1-421.e6. doi: 10.1016/j.jpurol.2018.03.026.\u003c/li\u003e\n\u003cli\u003eDekalo S, Ben-David R, Bar-Yaakov N, Dubi-Sobol A, Ekstein M, Ben-Chaim J, Bar-Yosef Y. In Support of a Simple Urethrocutaneous Fistula Closure Technique Following Hypospadias Repair. Urology. 2020 Sep;143:212-215. doi: 10.1016/j.urology.2020.06.015.\u003c/li\u003e\n\u003cli\u003eSnodgrass W, Grimsby G, Bush NC. Coronal fistula repair under the glans without reoperative hypospadias glansplasty or urinary diversion. J Pediatr Urol. 2015 Feb;11(1):39.e1-4. doi: 10.1016/j.jpurol.2014.09.007.\u003c/li\u003e\n\u003cli\u003eDokter EMJ, Slikboer KMA, van der Zanden LFM, Rahamat-Langendoen JC, Henriet SSV, Feitz WFJ, Kortmann BBM, Roeleveld N, van Rooij IALM. Preoperative Illnesses in Children Do Not Increase the Risk of Complications After Hypospadias Repair. Pediatr Infect Dis J. 2019 Feb;38(2):104-109. doi: 10.1097/INF.0000000000002064.\u003c/li\u003e\n\u003cli\u003eZhang Y, Chao M, Zhang WP, Tang YM, Chen HC, Zhang KP, Lu RG, Zhang XS, Lou DH. Using Buck\u0026apos;s Fascia as an Integral Covering in Urethroplasty to Restore the Anatomical Structure of the Penis in One-Stage Hypospadias Repair: A Multicenter Chinese Study Comprising 1,386 Surgeries. Front Pediatr. 2021 Aug 9;9:695912. doi: 10.3389/fped.2021.695912.\u003c/li\u003e\n\u003cli\u003eLiao AY, Smith GH. Urethrocutaneous fistulae after hypospadias repair: When do they occur? J Paediatr Child Health. 2016 May;52(5):556-60. doi: 10.1111/jpc.13102.\u003c/li\u003e\n\u003cli\u003eJohnston AW, Jibara GA, Purves JT, Routh JC, Wiener JS. Delayed presentation of urethrocutaneous fistulae after hypospadias repair. J Pediatr Surg. 2020 Oct;55(10):2206-2208. doi: 10.1016/j.jpedsurg.2019.12.025.\u003c/li\u003e\n\u003cli\u003eBar-Yosef Y, Ben-Chaim J, Ekstein M, Ben-David R, Savin Z, Yossepowitch O, Mano R, Dekalo S. Concomitant Repair of Meatal Stenosis and Urethral Fistula Does Not Increase the Risk of Fistula Recurrence Post Hypospadias Surgery. Urology. 2022 Feb; 160:187-190. doi: 10.1016/j.urology.2021.11.029.\u003c/li\u003e\n\u003cli\u003eTian G, Guo B, Zhang L. Analysis of influencing factors of multiple urethrocutaneous fistula after urethroplasty in children with hypospadias. Front Pediatr. 2023 Mar 21; 11:1103200. doi: 10.3389/fped.2023.1103200.\u003c/li\u003e\n\u003cli\u003eYang F, Ruan J, Zhao Y, Zhu L, Wang X, Chen G. Individual treatment strategy for single urethrocutaneous fistula after hypospadias repair: a retrospective cohort study. Transl Androl Urol. 2022 Sep;11(9):1345-1353. doi: 10.21037/tau-22-559. \u003c/li\u003e\n\u003cli\u003eWood HM, Kay R, Angermeier KW, Ross JH. Timing of the presentation of urethrocutaneous fistulas after hypospadias repair in pediatric patients. J Urol. 2008 Oct;180(4 Suppl):1753-6. doi: 10.1016/j.juro.2008.03.112.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBaseline Patient Characteristics\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eTotal patients, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e136\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eUCF repair success, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e105 (77.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eAge (month), median (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52 (20\u0026ndash;204)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eFollow-up time (month), median (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36.2 (11\u0026ndash;120)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eType of HR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003epreservation of the urethral plate (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTIP (DIG)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOIF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003etransection of the urethral plate (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTPIF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKoyanagi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStaged repair\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eHR: hypospadias repair; TIPU: tubularized incised plate urethroplasty; DIF: dorsal inlay graft; OIF: onlay island flap; TPIF: transverse preputial island flap;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eUnivariate analysis of variables related to UCF recurrence.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;136)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eUCF cured (n\u0026thinsp;=\u0026thinsp;105)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eUCF recurrence (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStatistic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBMI, M (Q₁, Q₃)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e15.50 (14.54, 16.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.50 (14.58, 16.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e15.57 (14.41, 16.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.986\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge at UCF repair, M (Q₁, Q₃)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e52.00 (36.00, 79.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52.00 (35.00, 82.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e55.00 (42.50, 75.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.755\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.450\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge at urethroplasty, M (Q₁, Q₃)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e35.00 (19.00, 60.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34.00 (19.00, 61.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e41.00 (25.50, 53.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.649\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.517\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLength of neourethra, M (Q₁, Q₃)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e3.00 (2.00, 3.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.00 (2.00, 3.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e3.00 (2.00, 4.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.074\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.941\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInterval time of urethroplasty and UCF occurrence, M (Q₁, Q₃)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e21.00 (14.00, 28.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.00 (14.00, 28.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e14.00 (10.00, 28.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.540\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.013*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSize of UCF, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"6\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026chi;\u0026sup2;\u003c/em\u003e=8.033\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003e0.018*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;2mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e47 (34.56%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41(39.05%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e6 (19.35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e≧\u0026thinsp;2mm, \u0026lt;4mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e75 (55.15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57 (54.28%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e18 (58.06%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e≧\u0026thinsp;4mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e14 (10.29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (6.67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e7 (22.58%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInterval time of UCF repair and urethroplasty, M (Q₁, Q₃)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e13.00 (10.75, 20.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.00 (10.00, 19.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e14.00 (12.00, 24.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.962\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.337\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber of UCFs, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOne\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e117 (86.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e96 (91.43%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e21 (67.74%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026chi;\u0026sup2;\u003c/em\u003e=9.289\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.002*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003emultiple\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e19 (3.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (8.57%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e10 (32.26%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHistory of prematurity, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"8\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e122 (89.71%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e93 (88.57%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e29 (93.55%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026chi;\u0026sup2;\u003c/em\u003e=0.216\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.642\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e14 (10.29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (11.43%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e2 (6.45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHistory of low birth weight, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"8\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e104 (76.47%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e77 (73.33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e27 (87.10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026chi;\u0026sup2;\u003c/em\u003e=2.520\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.112\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e32 (23.53%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (26.67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e4 (12.90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLocation of UCF, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"8\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-Coronal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e86 (63.24%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e74 (70.48%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e12 (38.71%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026chi;\u0026sup2;\u003c/em\u003e=10.389\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.002*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCoronal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e50 (36.76%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (29.52%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e19 (61.29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOperative approaches during HR, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"8\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreserve the urethral plate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e60 (44.12%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44 (41.90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e16 (51.61%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026chi;\u0026sup2;\u003c/em\u003e=0.915\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.339\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTransect the urethral plate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e76 (55.88%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61 (58.10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e15 (48.39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrethral recover during HR, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"8\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBuck\u0026rsquo;s fascia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70 (51.47%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e61 (58.10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (29.03%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026chi;\u0026sup2;\u003c/em\u003e=8.093\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.004*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003edartos fascia/ tunica vaginalis flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66 (48.53%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e44 (41.90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (70.97%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMeatal stenosis, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"8\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e131 (96.32%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e103 (98.10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e28 (90.32%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026chi;\u0026sup2;\u003c/em\u003e=2.183\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.140\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e5 (3.68%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1.90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e3 (9.68%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"9\"\u003e\n \u003cp\u003e* \u003cem\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.1\u003c/em\u003e were considered statistically significant; HR hypospadias repair\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBinary logistic regression analysis of variables related to UCF recurrence.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBeta\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eS.E.\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eWald\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDf\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOR (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eLocation of UCFs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-coronal#\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e1.087\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.487\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e4.984\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.026*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e2.964 (1.142\u0026ndash;7.695)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ecoronal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eSize of UCFs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;2mm#\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.257\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.044*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e≧\u0026thinsp;2mm, \u0026lt;4mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.755\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.569\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.762\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.184\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.129 (0.698\u0026ndash;6.495)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e≧\u0026thinsp;4mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.941\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.776\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.257\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.012*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.968 (1.522\u0026ndash;31.898)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eNumber of UCFs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOne#\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e1.391\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.582\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e5.707\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.017*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e4.017 (1.284\u0026ndash;12.571)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMultiple\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eUrethral covering during HR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBuck\u0026rsquo;s fascia#\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.967\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.486\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e3.961\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.047*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e2.631 (1.015\u0026ndash;6.819)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003edartos fascia/tunica vaginalis flap\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInterval time of urethroplasty and UCF occurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.892\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.345\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.015 (0.984\u0026ndash;1.048)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"8\" style=\"width: 99.78%;\"\u003e\n \u003cp\u003e*P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant #control group UCF: urethrocutaneous fistula; HR: hypospadias repair\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\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":"urethrocutaneous fistula, hypospadias, risk factors, child, recurrence","lastPublishedDoi":"10.21203/rs.3.rs-4658990/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4658990/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study aimed to identify risk factors associated with the recurrence of urethrocutaneous fistula (UCF) following repair in patients with hypospadias, beyond the intrinsic characteristics of the fistula itself.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical data of patients who underwent UCF repair were retrospectively reviewed. Potential risk factors included age and body mass index at UCF repair, history of low birth weight and prematurity, urethral defect length, operative approaches and urethral covering during hypospadias repair (HR), interval between urethroplasty and UCF presentation, interval between urethroplasty and UCF repair, meatal stenosis, size, number and location of UCFs. Univariate and multivariate analysis were used to identify the risk factors of UCF recurrence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 136 patients underwent UCF repair from 2013 to 2022, and UCF recurred in 31 patients (22.8%) after a median follow-up of 36.2 months. Results of multivariate analysis showed that the UCF with a diameter exceed 4mm (\u003cem\u003eOR\u003c/em\u003e6.968, \u003cem\u003e95% CI\u003c/em\u003e 1.522–31.898, \u003cem\u003eP\u003c/em\u003e=0.012), multiple UCFs (\u003cem\u003eOR\u003c/em\u003e 4.017, \u003cem\u003e95% CI\u003c/em\u003e 1.284–12.571, \u003cem\u003eP\u003c/em\u003e=0.017), coronal UCF (\u003cem\u003eOR\u003c/em\u003e 2.964, \u003cem\u003e95% CI\u003c/em\u003e 1.142–7.695, \u003cem\u003eP\u003c/em\u003e=0.026) and urethral covering with non-Buck’s fascia \u0026nbsp;(\u003cem\u003eOR\u003c/em\u003e 2.631, \u003cem\u003e95% CI\u003c/em\u003e 1.015–6.819, \u003cem\u003eP\u003c/em\u003e=0.047) were statistically significant, correlating with the risk of UCF recurrence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUCF repair was more prone to failure if the size of UCF exceeds 4 mm, if it is located at the coronary sulcus, if multiple UCFs are present. Employing Buck’s fascia during HR would reduce the incidence of UCF recurrence.\u003c/p\u003e","manuscriptTitle":"Predictors of Treatment Failure in Urethrocutaneous Fistula Repair for Hypospadias: A Retrospective Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-23 14:11:47","doi":"10.21203/rs.3.rs-4658990/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":"cb48116a-33a1-4cd0-bb6c-0b7773460615","owner":[],"postedDate":"July 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-04T20:08:31+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-23 14:11:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4658990","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4658990","identity":"rs-4658990","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}