Non-operative management of early onset small urethrocutaneous fistula post hypospadias repair: a systematic review

BACKGROUND: Urethrocutaneous fistulas (UCF) after hypospadias repair are typically managed surgically, but conservative approaches may offer a less invasive, cost-effective alternative. While surgical repair remains the standard, non-operative strategies may eliminate anesthesia exposure, shorten recovery time, and lower healthcare costs. However, systematic evidence regarding these approaches remains limited. METHODS: This narrative systematic review evaluates non-operative management for small (typically ≤ 2 mm) UCFs. A comprehensive search was conducted across PubMed, Cochrane, ScienceDirect, Wiley, and Google Scholar up to April 2025. The study followed PRISMA guidelines and is registered in PROSPERO (CRD420251069870). We included randomized controlled trials (RCTs), comparative trials, case series, and anecdotal reports involving children (< 18 years). Risk of bias was assessed using Cochrane RoB-2, ROBINS-I, and JBI Critical Appraisal tools. RESULTS: Five studies involving 73 patients were included for analysis. Due to significant clinical heterogeneity in fistula characteristics and interventions, a pooled closure rate was not calculated. Reported individual study closure rates ranged from 53.8% to 62.5% in the primary series, with one anecdotal report (n = 1) showing 100% success. Success was more frequently observed in early-onset UCFs (diagnosed within 14 days post-catheter removal) and those with a diameter ≤ 2 mm. Minor adverse events included localized heat (42.8%) and transient dysuria (4.7%). Cost-analysis from one RCT indicated that non-operative adhesive application cost approximately 9.3% compared to total operative costs. Most included studies were classified as having a high risk of bias. CONCLUSION: Non-operative approaches using tissue adhesives, fibrin glue, or recatheterization may be viable for small (≤ 2 mm), early-onset UCFs. However, the current evidence is limited, heterogeneous, and carries a high risk of bias. These findings should be considered hypothesis-generating, and further high-quality comparative studies are required to establish definitive clinical protocols. TRIAL REGISTRATION: PROSPERO CRD420251069870.