Hypospadias is one of the most common urological anomalies in boys. While 80% of all hypospadias are mild and of distal or midpenile, 20% are proximal hypospadias. Severe varieties like scrotal hypospadias form only 5% of total burden of hypospadias. Severe hypospadias such as scrotal hypospadias often have associated chordee (bent penis) and this may be very severe too posing a challenge for the hypospadias surgeon. We have realized in last few years that making the penis straight (chordee correction) is THE MOST IMPORTANT step of hypospadias repair procedure. While most of the severe scrotal hypospadias are also repaired in a single stage (almost 90% are suitable for a single stage urethroplasty), in 10% of the children the anomaly is so severe especially due to severe chordee that two stage repair may be better for an optimal long term outcome.
Master R.P. was born with scrotal hypospadias, severe chordee in Patna, Bihar and was advised to undergo surgery after 1 year of age. The parents went to multiple doctors in Patna, Delhi and finally came to consult Dr A.K.Singal, renowned Hypospadias surgeon at MITR Hospital, Navi Mumbai. On examination, the child had a severe scrotal hypospadias, severe chordee (almost 90 degrees) and abnormally fused skin of scrotum to the penis. This almost looked like a trapped hypospadias penis due to skin shortage. Dr Singal discussed in detail with parents that such a severe hypospadias may require hypospadias treatment in stages. Due to the severity it may be impossible to correct all the defects in one surgery. Also the penis length may have got shortened and cosmetic result would also been suboptimal.
Finally, R.P. was taken under anesthesia and hypospadias repair surgery was started. As a first step the penis was degloved. Urethral plate was divided and the fibrous bands causing chordee on the underside of penis were divided deeply till the scrotum. The penis was almost straight after this maneuver with just 30 degree bend which was further corrected by a placing a placating stitch on the top side of penis (tunica albuginea plication or TAP). Artificial erection test confirmed the complete correction of chordee. Since the chordee was severe and the urethral plate was also divided, single stage surgery would have carried very high failure rates. Hence, a staged urethroplasty was planned. The skin on the top of the penis was divided in midline and brought to the underside of penis. A part of the skin was advanced into the head of penis (glans) so that the new urethra in next stage would be constructed till the tip of penis. This is called Thiersch Byar’s urethroplasty stage-1. There was a compression dressing done which was removed after 7 days and the family travelled back to Patna after a total of 14 days after first hypospadias surgery.
Happy family with Dr Singal after Surgery
The family sent us some pictures in the healing phase over next few months and the second stage urethroplasty was planned after 6 months of first hypospadias surgery. When we saw the patient again – the flaps and the skin on the underside was very well healed and ready for second stage. Second stage urethroplasty was done and it took just 2 hours for the surgery. The catheter was removed after ten days and the R.P. passed urine in a good stream from the tip of the penis like a normal boy. Family was delighted and after another follow-up visit one week later they travelled back to Bihar.
According to Dr Singal, “With the experience and expertise, currently we do single stage surgery for even scrotal hypospadias and other complex hypospadias. The only limiting factor is the severity of the chordee. Sometimes in sever chordee we need to apply a cut on the underside of penis to straighten it. In such cases, it is better to do a staged repair. In our experience, two stage hypospadias surgery can have excellent cosmetic and functional results. It also provided a longer penis length by straightening the penis and elongating the underside of penis when chordee correction is done.
About the author:
Dr A.K.Singal is a senior Pediatric Urologist and a renowned Hypospadias expert surgeon in Navi Mumbai, India. Every year he operates more than 200 kids and adults with hypospadias from all over the world and from all over India. Dr Singal has done lot of clinical research and conducted training programs for hypospadias surgery in India. Due to expertise in managing complex cases of severe hypospadias and failed hypospadias operated elsewhere, he is counted as one of the best and top hypospadias surgeons in India.
Dr A.K.Singal delivering his talk at ESPU
About Hypospadias Foundation:
Hypospadias Foundation is World’s first and only organisation dedicated to care and cure of children and adults with hypospadias. Started in 2008 by Dr Singal and Dr Dubey, more than 1000 patients have benefitted from care at the foundation from more than 20 countries. The blessings and goodwill only continues to grow from a single point focus of excellence in hypospadiology. The foundation soon intends to start formal training courses in Hypospadias surgery for international doctors.
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Watch video of Scrotal hypospadias surgery repair by Dr Singal
Watch video of Proximal penile hypospadias surgery by Dr Singal
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