Case in which percutaneous fibrin glue injection was useful for refractory urinary fistula following robot-assisted partial nephrectomy.

Introduction: Urinary fistula is a rare complication following robot-assisted partial nephrectomy. For cases refractory to conservative treatment, only ureteral stent placement and percutaneous drainage are the established treatment alternatives. Case presentation: A 44-year-old man presented with urinary fistula 3 weeks after robot-assisted partial nephrectomy for right renal cell carcinoma. Follow-up observations were conducted for 2 weeks; however, no improvements were observed. Additionally, the patient did not improve following percutaneous drainage and ureteral stent insertion. Subsequently, the patient received percutaneous injections of fibrin glue, with the urinary fistula showing significant improvements on the following day. Conclusion: Our findings indicated that percutaneous fibrin glue injection can effectively treat refractory urinary fistula following partial nephrectomy.

Long-term ileoanal pouch survival after pouch urinary tract fistulae.

BACKGROUND: Ileoanal pouch is a demanding procedure with many potential technical complications including bladder or ureteral injury, while inflammation or stricture of the anastomosis or anal transition zone may lead to the formation of strictures and fistulae, including to the adjacent urethra. Pouch urinary tract fistulae are rare. We aimed to describe the presentation, diagnostic workup, and management of patients with pouch urinary at our center. METHODS: Our prospectively maintained pouch registry was queried using diagnostic codes and natural language processing free-text searches to identify ileoanal pouch patients diagnosed with any pouch-urinary tract fistula from 1997 to 2022. Descriptive statistics and pouch survival using Kaplan-Meier curves are presented. Numbers represent frequency (proportion) or median (range). RESULTS: Over 25 years, urinary fistulae were observed 27 pouch patients; of these, 16 of the index pouches were performed at our institution [rate 0.3% (16/5236)]. Overall median age was 42 (27-62) years, and 92.3% of the patients were male. Fistula locations included pouch-urethra in 13 patients (48.1%), pouch-bladder in 12 patients (44.4%), and anal-urethra in 2 (7.4%). The median time from pouch to fistula was 7.0 (0.3-38) years. Pouch excision and end ileostomy were performed in 12 patients (bladder fistula, n = 3; urethral fistula, n = 9), while redo ileal pouch-anal anastomosis (IPAA) was performed in 5 patients (bladder fistula, n = 3; urethral fistula, n = 2). The 5-year overall pouch survival after fistula to the bladder was 58.3% vs. 33.3% with urethral fistulae (p = 0.25). CONCLUSION: Pouch-urinary tract fistulae are a rare, morbid, and difficult to treat complication of ileoanal pouch that requires a multidisciplinary, often staged, surgical approach. In the long term, pouches with bladder fistulae were more likely to be salvaged than pouches with urethral fistulae.

Transcatheter renal arterial embolization for intractable urinary fistula occurring after robot-assisted partial nephrectomy: a case report.

Partial nephrectomy is the standard surgical procedure for small renal tumors. Since the advent of robot-assisted partial nephrectomy (RAPN), the number of cases of renal tumors undergoing the procedure has increased exponentially. Urinary fistula is a complication of partial nephrectomy. Conservative management using ureteral stents is useful in most cases of urinary fistulas. However, some patients develop intractable urinary fistulas. Herein, we report a case in which vascular embolization was useful for treating an infected and intractable urinary fistula that developed after RAPN. A 59-year-old man was accidentally found to have a right renal tumor (approximately 3 cm in diameter) during a physical examination. Pathology was clear cell carcinoma. RAPN was performed owing to the small size of the renal tumor; however, postoperatively, an intractable urinary fistula with an isolated calyx developed, which was successfully treated with transcatheter renal arterial embolization (TAE). We encountered a rare case of infected refractory urinary fistula with an isolated calyx in which TAE was successful. TAE seems useful in treating intractable urinary fistulas with an isolated calyx occurring after RAPN.

[Urinary diversion with or without simple cystectomy as a salvage option for benign diseases of the lower urinary tract]. / Harnableitungen mit oder ohne simple Zystektomie in der Salvage-Therapie benigner Erkrankungen des unteren Harntraktes.

Benign diseases of the lower urinary tract can occur as a result of oncological or neurological diseases or their respective therapies (e.g., surgery or radiation treatment) and can significantly reduce the quality of life for affected patients. Urinary diversion serves as a salvage option when all other therapeutic regimens have been carried out and proven unsuccessful. When selecting the suitable urinary diversion, a comprehensive clinical assessment of the patients is required in order to ensure long-term success. In some cases, a cutaneous, catheterizable pouch offers the last and only option for a long-term and definitive treatment of a patient's condition. Overall, a decreasing trend in the establishment of a continent urinary diversion is observed in Germany. Current data on benign indications for urinary diversion are limited. Therefore, further data collection and research are needed.

Pubosymphyseal Urinary Fistula Following Radiation Therapy of Bladder Sarcomatoid Tumor.

Pubosymphyseal urinary fistula (PUF) is a rare condition that involves an abnormal connection between the urinary bladder and the pubic bone. It can occur after trauma, radiation therapy, or surgery to the pelvis. It is also reported with chronic indwelling Foley catheter use. In this case report, we present a 56-year-old male who developed a fistula complicated by osteomyelitis pubis following external beam radiation for a urinary bladder sarcomatoid tumor. Patients at high risk of PUF may present with urinary leakage, pelvic pain, and infection, making diagnosis challenging. The condition can lead to chronic pelvic pain and long-term opioid use if left untreated. Diagnosis is typically made through imaging studies (CT scan or MRI) and confirmed with cystoscopy. Treatment usually involves urinary diversion/surgical repair of the fistula and management of any associated infection or complications. The prognosis is generally good if the condition is diagnosed and treated promptly. While it is rare, it can have significant consequences that require prompt diagnosis and treatment.

Colo-renal Fistula in a Patient With Refractory Anemia and Recurrent Urinary Tract Infections: A Case Report and Review of the Literature.

Although rare, colo-renal fistulas pose diagnostic challenges due to their varied presentations and etiologies. Here, we present a unique case of a woman with recurrent pyelonephritis, severe anemia, and unintended weight loss, who was eventually diagnosed with a colo-renal fistula. Delayed imaging following intraoperative fluoroscopy revealed the abnormal connection between the colon and upper urinary tract. The patient underwent nephrectomy and colon resection. This case report emphasizes the need for suspicion in diagnosing such fistulas and highlights their varied management. This case adds to the literature by illustrating an unusual presentation and underscores the complexity of diagnosis and treatment.

A Very Rare Disease of Patent Urachus Cyst With Vesico-Umbilical Urinary Fistula in Adults: A Case Report and Short Review.

Rare developmental anomalies known as urachal remnants are brought on by flaws in the foetal developmental process. However, depending on the location and degree of incomplete obliteration, the urachus can undergo a variety of urachal anomalies. An umbilical fistulogram and a voiding cystourethrogram both supported the existence of the adult urachal cyst in this case. To treat the sepsis, we provided the patient with antibiotics first, then a surgical procedure. The entire vesico-umbilical tract with the urachal cyst was removed using the open approach. The excised specimen's histology revealed a foreign body giant cell reaction without any indication of malignancy. The presentation and diagnosis of vesico-umbilical urinary fistula (VUUF) in adults can occasionally be difficult. They happen very rarely. So we began putting forward this case for the same reason.

Risk factors for and delayed recognition of genitourinary fistula following radical hysterectomy for cervical cancer: a population-based analysis.

OBJECTIVE: This study aimed to identify the risk factors for genitourinary fistulas and delayed fistula recognition after radical hysterectomy for cervical cancer. METHODS: This study was a retrospective analysis of data collected in the Major Surgical complications of Cervical Cancer in China (MSCCCC) database from 2004-2016. Data on sociodemographic characteristics, clinical characteristics, and hospital characteristics were extracted. Differences in the odds of genitourinary fistula development were investigated with multivariate logistic regression analyses, and differences in the time to recognition of genitourinary fistula were assessed by Kruskal-Wallis test. RESULTS: In this study, 23,404 patients met the inclusion criteria. Surgery in a cancer center, a women's and children's hospital, a facility in a first-tier city, or southwest region, stage IIA, type C1 hysterectomy, laparoscopic surgery and ureteral injury were associated with a higher risk of ureterovaginal fistula (UVF) (p<0.050). Surgery in southwest region, bladder injury and laparoscopic surgery were associated with greater odds of vesicovaginal fistula (VVF) (p<0.050). Surgery at cancer centers and high-volume hospitals was associated with an increase in the median time to UVF recognition (p=0.016; p=0.005). International Federation of Gynecology and Obstetrics (FIGO) stage IIA1-IIB was associated with delayed recognition of VVF (p=0.040). CONCLUSION: Intraoperative urinary tract injury and surgical approach were associated with differences in the development of UVFs and VVFs. Patients who underwent surgery in cancer centers and high-volume hospitals were more likely to experience delayed recognition of UVF. Patients with FIGO stage IIA1-IIB disease were more likely to experience delayed recognition of VVF.

Incidental urinary tract injury and the formation of vesicovaginal fistula at the time of hysterectomy for benign indications.

INTRODUCTION AND HYPOTHESIS: The association between hysterectomy type, laparoscopy use and vesicovaginal fistula (VVF) is currently unclear and would be useful to determine route of surgery and provide adequate patient counseling. The objective of this study was to evaluate the magnitude of association between the use of laparoscopic assistance, recognized intraoperative urinary tract injury and subsequent VVF repair and to quantify any differences in fistula repair and injury detection by hysterectomy type. Lastly, we sought to determine whether the type of hysterectomy is a risk factor for VVF repair independent of injury identification. METHODS: We performed a retrospective cohort study utilizing the Healthcare Cost and Utilization Project database examining benign hysterectomies performed in California, New York and Florida from 2005-2011. Multivariable logistic regression models were used to evaluate associations among hysterectomy type, reported injury and VVF. RESULTS: Of 581,395 eligible hysterectomies, urinary tract injuries occurred in 6702 patients (1.15%) and 640 patients developed VVF (0.11%). Patients with reported injury were 20-fold more likely to develop VVF than those without (OR = 20.6; 1.96% vs. 0.089% respectively). The association between reported injury and VVF development was stronger if laparoscopy was involved (OR = 30) than if it was not (OR = 17). Patients undergoing laparoscopic procedures were less likely to have injury reported (OR = 0.6) but more likely to undergo VVF repair (OR = 1.5). This association with VVF repair was independent of injury identification. Patients developing VVF were more likely to have undergone total abdominal hysterectomy compared to other hysterectomy types. CONCLUSIONS: Laparoscopy is an independent risk factor for the need for subsequent VVF repair, independent of hysterectomy type and presence of intraoperatively recognized urinary tract injury.

Clinical analysis of human acellular allogeneic dermis in the repair of urinary fistula / 现代泌尿外科杂志

【Objective】 To investigate the clinical efficacy of human acellular allogeneic dermis (HADM) in the repair of urinary fistula. 【Methods】 The clinical data of 12 female patients with complex vesicovaginal fistula treated during Jun.2021 and Nov.2022 were retrospectively analyzed. The patients’ average age was 47.3 years, ranging from 38 to 56 years. The body mass index (BMI) ranged from 16.6 to 25.2, with an average of 21.3. HADM was inserted between vagina and bladder wall fistula to repair fistula in all 12 patients. 【Results】 All operations were successful. After the operation, the vaginal urine leakage stopped and the urinary tube was retained for 2 weeks. During the postoperative follow-up of 1 to 16 months, no recurrence or complication were observed. 【Conclusion】 Transvaginal HDMA is an ideal surgical method in the treatment of complex vesicovaginal fistula, which has advantages of small trauma, fast recovery and high success rate.

Management of osteomyelitis of the pubic symphysis following urinary fistula in patients with radiation-induced urethral strictures after prostate cancer treatment.

Introduction: Osteomyelitis of the pubic symphysis is a rare condition often occurring in patients with radiation therapy-related urethral strictures after prostate cancer treatment. Material and methods: We retrospectively reviewed patients who presented with osteomyelitis of the pubic symphysis from November 2016 to September 2021. We investigated the factors leading to urosymphyseal fistulas, clinical presentation, radiological assessment, treatments, and outcomes. Results: A total 4 cases were collected. All patients underwent surgery and adjuvant or salvage radiotherapy for prostate cancer. Subsequently, they developed stricture of the vesicourethral anastomosis which was initially treated conservatively. Symptoms of pubic bone osteomyelitis included pain in the pubic area, fever, difficulty walking, and recurrent urinary tract infections. In all cases, computed tomography and magnetic resonance imaging showed a urinary fistula arising from the vesicourethral anastomosis with the involvement of the pubic bone, and severe osteomyelitis. Due to the failure of conservative treatment, debridement of the pubic bone with cystectomy and ileal conduit was performed in 3 patients. One patient refused surgery and bilateral percutaneous nephrostomies were placed. Patients regained their original performance status 1 to 6 months after surgery. Conclusions: General recommendations for the best diagnostic and therapeutic approach to osteomyelitis of the pubic symphysis due to urosymphyseal fistula still do not exist. Conservative treatment often fails and a surgical approach with definitive urinary diversion may be required.

Biologic adjuvant urethral coverings for single-stage primary hypospadias repairs: A systematic review and pooled proportional meta-analysis of postoperative urethrocutaneous fistulas.

BACKGROUND: The use of barrier layers between the neourethra and skin is associated with lower rates of post-operative urethrocutaneous fistula (UCF) following hypospadias surgery. Recent studies have evaluated the ability of biologic adjuvant urethral coverings (BAUCs) - namely acellular matrix (AM), tissue adhesives (TAs), and autologous platelet-rich plasma or fibrin (PRP/PRF) - to prevent wound complications following hypospadias surgery. In general, however, these studies are small and conducted at single institutions. OBJECTIVE: To assess the effect of BAUCs on the rate of UCF following single-stage primary hypospadias repair. METHODS: We conducted a systematic review of studies reporting the rate of postoperative UCF in pediatric patients undergoing single-stage, primary hypospadias repairs using either AM, TA, or PRP/PRF as a layer interposed between the neourethra and skin. We then performed a pooled proportional meta-analysis of post-operative UCF. Patients within each study who underwent comparable surgery but did not receive a BAUC were used as controls. RESULTS: 10 studies were included in our review. The meta-analysis included 280 patients from 7 studies who underwent hypospadias repairs with BAUCs. The pooled incidence of UCF was 10% (95% CI 6-14%). Mean follow-up ranged 5-23.5 months in the 5/7 studies reporting specific durations, and ≥6 month and 14-30 months, respectively, in the other two studies. Patients in whom a BAUC was used had significantly lower odds of UCF than control patients (OR 0.39, 95% CI 0.24-0.64, p = 0.0002). In subgroup analyses, significant superiority held for AM and TA; proximal or penoscrotal cases; transverse preputial island flap (TPIF) technique; when both cases and controls had local flaps; and when neither cases nor controls had flaps. DISCUSSION: The use of BAUCs was associated with decreased rates of post-operative UCF in single-stage primary hypospadias repairs and may be most beneficial in more severe cases and when used in addition to local flaps or when using a flap is not possible. In 2/3 studies of PRP/PRF and 2/4 studies of tubularized incised plate (TIP) technique, dartos flaps were used in controls but not BAUC patients, which may explain the lack of benefit demonstrated for these subgroups. This meta-analysis is limited by the quality of evidence in the included studies, which are not uniformly randomized. Furthermore, the follow-up durations and methods for assessing complications are not standardized between included studies. CONCLUSION: The meta-analysis herein suggests that using BAUCs may reduce UCF rates following hypospadias surgery. Rigorous prospective evaluation is needed to validate this benefit.

Revisión sistemática del tratamiento activo de la fístula urinaria después de la nefrectomía parcial / Systematic review on active treatment for urinary fistula after partial nephrectomy

Introducción Cabe esperar que la frecuencia de la fístula urinaria en la práctica urológica aumente como consecuencia de la ampliación de las indicaciones de la nefrectomía parcial, dado que obtiene resultados oncológicos equivalentes a los de la nefrectomía radical, pero con un menor riesgo de progresión a enfermedad renal crónica, menor morbilidad cardiovascular y mortalidad global. Objetivos Revisar y comparar las diferentes técnicas actuales de tratamiento activo para la fístula urinaria después de la nefrectomía parcial. Métodos Se realizó una búsqueda bibliográfica sistemática en la base de datos MEDLINE en marzo de 2020, combinando los términos: «urine leak», «urine leakage», «urinary leak» y «urinary fistula», con: «partial nephrectomy», «nephron sparing surgery» y «renal sparing surgery». Esta revisión sistemática se realizó de acuerdo con las guías de la declaración Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). Solo se eligieron los artículos relacionados con el tratamiento activo. Se seleccionaron los resúmenes en inglés y español de las 2 últimas décadas. No hubo restricciones respecto al diseño del estudio ni la duración del seguimiento. Resultados primarios: 1) Tasa de resolución de la fuga, 2) Periodo de tiempo hasta la resolución de la fuga y 3) Número de intervenciones requeridas para la resolución. Resultados Se encontraron varios estudios. No hubo ningún ensayo controlado aleatorizado. La fístula urinaria puede resolverse de muchas maneras con el tratamiento activo, con una alta tasa de éxito (97,5%), una media de 1,4 intervenciones por paciente y un tiempo medio hasta la resolución de la fístula de 11 días (mediana de 3 días). Conclusión Existe un alto riesgo de sesgo debido a la metodología de los estudios. Sin embargo, hay un amplio abanico de alternativas eficaces y diversos abordajes para resolver la fístula urinaria en un periodo de tiempo adecuado (AU)

Introduction Urinary fistula is expected to become more frequent in urological practice as a result of expanding indication of partial nephrectomy given it́s oncological results equivalent to those of radical nephrectomy but at a lower risk of progression to chronic kidney disease, lower cardiovascular morbidity, and overall mortality. Objectives Review and compare different techniques of contemporary active management for urinary fistula after partial nephrectomy. Methods A systematic literature search on the MEDLINE database was conducted in March 2020, combining the terms: «urine leak», «urine leakage», «urinary leak» and «urinary fistula», with: «partial nephrectomy», «nephron sparing surgery» and «renal sparing surgery». The review of the literature was performed accordingto the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Only articles related to active treatment were eligible. Abstracts in English and Spanish from the last two decades were screened. No restriction based on study design nor the length of follow-up. Primary outcomes: 1) Leak resolution rate 2) Time course of leak resolution and 3) Number of interventions needed for resolution. Results Multiple studies were found. There were no randomized controlled trials. Urinary fistula can be solved in many ways with active treatment, with a high success rate (97.5%), an average of 1.4 intervention-per-patients and a mean time for leak resolution of 11 days (median of 3 days). Conclusion There is a high risk of bias due to the study's methodology. There is a broad range of effective alternatives and various approaches to solve urinary fistula in an appropriate timing (AU)

Transrenal Ureter Embolization for Refractory Urine Leaks from Iatrogenic Ureteric Injury Following Colorectal Surgery.

We present the cases of two patients who underwent ureteral occlusion using coils and/or Amplatzer Vascular Plug with N-butyl cyanoacrylate glue after extensive advanced rectal surgery. Both patients had complex urine leaks unresponsive to urinary diversion. In view of the progress of the disease and the history of polysurgery, reconstructive surgery or anterograde ureteral stent insertion was not chosen. All patients had immediate resolution of urinary leakage after ureteral embolization, resulting in symptom relief throughout the follow-up period. There were no procedure-related complications or side effects.

Conservative treatment of urinary fistula: Case report.

Radical cystectomy is the gold standard treatment for muscular invasive bladder cancer. Bricker surgery is the most common technique used for urinary diversion; however, troublesome complications such as postoperative anastomotic stenosis or fistula may occur. The case of a patient who had a urinary fistula after Bricker surgery performed at our hospital, is described. The patient was successfully treated with continuous double-cannula negative-pressure drainage and avoided a second surgery. The patient recovered well and is on regular follow-up. This case highlights the importance of timely and relevant treatment for patients with postoperative urinary fistula to avoid more invasive surgery.

Systematic review on active treatment for urinary fistula after partial nephrectomy.

INTRODUCTION: Urinary fistula is expected to become more frequent in urological practice as a result of expanding indication of partial nephrectomy given it's oncological results equivalent to those of radical nephrectomy but at a lower risk of progression to chronic kidney disease, lower cardiovascular morbidity, and overall mortality. OBJECTIVES: Review and compare different techniques of contemporary active management for urinary fistula after partial nephrectomy. METHODS: A systematic literature search on the MEDLINE database was conducted in March 2020, combining the terms: "urine leak", "urine leakage", "urinary leak" and "urinary fistula", with: "partial nephrectomy", "nephron sparing surgery" and "renal sparing surgery". This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Only articles related to active treatment were eligible. Abstracts in English and Spanish from the last two decades were screened. No restriction based on study design nor the length of follow-up. PRIMARY OUTCOMES: 1) Leak resolution rate 2) Time course of leak resolution and 3) Number of interventions needed for resolution. RESULTS: Multiple studies were found. There were no randomized controlled trials. Urinary fistula can be solved in many ways with active treatment, with a high success rate (97.5%), an average of 1.4 intervention-per-patients and a mean time for leak resolution of 11 days (median of 3 days). CONCLUSION: There is a high risk of bias due to the study's methodology. There is a broad range of effective alternatives and various approaches to solve urinary fistula in an appropriate timing.

A simple score for predicting urinary fistula in patients with renal hydatid cysts.

Hydatid cyst is a major health problem in developing countries. The kidney is in third position of organs affected by hydatid cyst. One of the complications of renal hydatid cyst is a urinary fistula. The purpose of this study is to identify preoperative predictive factors of urinary fistula in renal hydatid cyst and to develop a scoring system for this disorder. We retrospectively analyzed all patients operated for renal hydatid cysts between January 2000 and December 2020. We divided our patients into two groups according to whether or not the renal hydatid cysts opened in the urinary tract. Predictive factors of the presence of a urinary fistula have been studied to obtain a simple score to predict the presence of a urinary fistula. Differences were considered significant if p < 0.05. Urinary fistula was detected in 33 of 96 patients. Univariate analyses showed significant differences in patient age, cyst size, location, hydaturia, eosinophil count, and platelet count between patients with and without urinary fistula. In multivariate analyses, hydaturia (p < 0.005), eosinophil count >500/mm3, (p = 0.01), cyst diameter >5 cm (p = 0.02), and upper or lower renal pole location (p = 0.003) were significant and independent predictors of urinary fistula. A score was developed to predict the opening of the cyst in the urinary tract. The total score varies between 0 and 15. The resulting area under the receiver operator characteristic curve was 0.798 (95% CI, 0.726-0.866; p = 0.023). At a cutoff point ≥8, the specificity achieved was 100%. Preoperative detection and management of urinary fistula are important issues in the treatment of renal hydatid cyst. Developing a scoring system based on routinely measured laboratory and radiologic factors will help the clinician to manage patients with renal hydatid cysts. External studies are needed to validate this new scoring system in routine clinical practice.

Comparison of post-urethroplasty complication rates in pediatric cases with hypospadias using Vicryl or polydioxanone sutures.

Objective: Hypospadias is a common congenital problem among male newborns. Both rapid absorbable sutures (polyglactin, Vicryl) and delayed absorbable sutures (polydioxanone, PDO) are used in hypospadias repair based on the surgeon's preference. This study was conducted to compare post-urethroplasty complication rates in pediatric patients with hypospadias using Vicryl or PDO sutures. Methods: This is a retrospective study which was designed and performed on 583 children aged 1-7 years old who had undergone hypospadias repair from January 2012 to December 2018. Required data were obtained from the patients' medical records. Results: Overall, post-surgical complications were observed in 60 (10.3%) patients comprising urethro-cutaneous fistula (n=39, 6.7%), meatal stenosis (n=10, 1.7%), urethral stricture (n=7, 1.2%), and glans dehiscence (n=4, 0.7%). The mean age of the children with complications was 3.0±1.3 years. According to Kaplan-Meier estimate, the interval between surgery and development of complications was significantly shorter in the Vicryl group (p=0.037). Overall, complications were more prevalent in Vicryl suture than PDO suture (15.1% vs. 5.3%, p<0.001). Regression model revealed that in comparison to the distal type, proximal hypospadias (odds ratio [OR]:103.9, 95% confidence interval [CI]: 32.2-334.9, p<0.001) and mid-shaft hypospadias (OR: 82.9, 95% CI: 25.9-264.6, p<0.001) while using Vicryl suture instead of PDO suture (OR: 62.4, 95% CI: 21.2-183.8, p<0.001) increased the odds of developing post-urethroplasty complications. Conclusion: We suggest PDO suture in the repair of hypospadias due to its lower complication rate, especially in cases of proximal and mid-shaft hypospadias which can get more complicated than the distal type.