Risk factors for urethrocutaneous fistula following hypospadias repair: a multisite prospective cohort study

Abstract Background Hypospadias is the second most common congenital external genital malformation in males, urethrocutaneous fistula (UCF) is the commonest complication of hypospadias repair. This study aimed to assess risk factors of UCF following hypospadias repair in (Khartoum) state, (Sudan), addressing both proximal and distal variants. Materials and methods This is an observational, prospective, multisite cohort study performed at six pediatric surgical centers from September 2021 to April 2023. Although data were abstracted from patient records, all entries were recorded prospectively from admission through follow-up using standardized forms. Children < 18 years undergoing hypospadias repair were included. Patients were followed for 12 months postoperatively. Variables included hypospadias location, surgical technique (including Byars or Bracka for proximal repairs), tissue coverage type, catheter size and duration, and surgeon experience. UCF was defined as any postoperative urethral leakage through the skin, excluding complete dehiscence. Patients were divided into two groups: those who developed UCF and those who did not. Chi-square, t-tests, and binary logistic regression were performed to identify independent risk factors for UCF. Results Among the enrolled patients ( n = 152), mean age was 2.5 ± 1.2 years. Forty-two percent had anterior hypospadias, 22% had middle hypospadias, and 36% had posterior hypospadias. Thirty-eight patients (25%) developed UCF; the mean time to development of UCF was 5.0 months. On univariate analysis, posterior hypospadias ( p = 0.01), catheter duration >7 days ( p < 0.001), and surgery performed by junior surgeons ( p = 0.04) were associated with UCF. Logistic regression analysis confirmed these as independent predictors. No patients were lost to follow-up during the study period. Meatal stenosis occurred in 3.3% and urethral stricture in 2.0% of patients, including 2 and 1 case(s), respectively, in the UCF group; no significant correlation was found, and their temporal relationship to UCF was not consistently recorded. Among UCF repairs, tunica vaginalis flap achieved 92% success (11/12) versus 77% (20/26) for skin flap or primary closure. Conclusions Independent risk factors for developing urethrocutaneous fistula include posterior meatal position, longer catheterization >7 days and limited surgeon experience. While stenosis and stricture were rare, their role in fistula formation warrants further study. Understanding these risk factors may help reduce UCF in resource-limited settings.