A.P., a 3-year-old male child, was brought to us with complaints of passing urine through an abnormal opening at the junction between the penis and scrotum with significantly bent penis (chordee), diagnosed as penoscrotal hypospadias with severe chordee and shortage of skin.
Clinical picture showing short penile skin in hypospadias
Clinical picture showing chordee- bending of the penis
After clinical examination, we had a long discussion with the parents, and we explained to them about the requirement of two stage surgery since the penile curvature (chordee) was very bad. Parents agreed for whatever was best for the child.
First stage Hypospadias Surgery- Chordee Correction & Byars Flaps:
The first stage of the surgery involves degloving the entire penis and chordee assessment by artificial erection test- also called Gitte’s test. After degloving, the chordee was very severe, almost 45 degrees. We divided the urethral plate, still the chordee was 15-20 degrees. We did a dorsal tunica albuginea plication to completely correct the chordee. Once chordee was corrected reassessment of chordee showed no chordee.
Clinical picture showing intra-operative chordee assessment
After division of urethral plate, still there is 15-20 degrees chordee
The prepuce was divided in the midline and rotated to be brought to the under surface of the penis, addressing penoscrotal hypospadias with severe chordee and a shortage of skin. At the end of stage 1, the chordee was completely corrected, and the inner layer of the rotated preputial skin was positioned in the midline on the under surface of the penis. This hairless preputial skin will be utilized in the second stage urethroplasty to create a new urethra.
Chordee fully corrected and Byars flaps brought ventrally.
Second stage Hypospadias Surgery- Urethroplasty
After 6 months of first hypospadias surgery, the child was taken up for the second stage hypospadias surgery. The prepucial flaps on inspection during second stage were wide and supple.
After 6 months, clinical picture showing wide and supple flaps
See healthy and well vascularised flaps
A catheter was placed, and a stay stitch taken on glans. 1.5cm wide incision made. Incisions were deepened till corpora and hemostasis checked.
Urethroplasty done over a 7 Fr catheter and in 2 layers with absorbable sutures. The Glans wings were raised, and a new meatus was made on the glans.
1.5 cm wide incision marked for urethroplasty
Urethroplasty done over 7Fr catheter
Surrounding dartos used for second layer coverage
The dressing in the post-operative period was removed at day 7 and catheter was removed at day 10. The suture line in penoscrotal hypospadias with severe chordee and shortage of skin healed well with no complication. Child was passing urine through the new opening in good stream. At 2 years follow-up child had no complications or issues.
Completed urethroplasty with meatus at glans
Result at end of 1 month with good meatus on glans and straight penis.
About Severe Chordee & Hypospadias Surgery:
The most important factor in decision making for any hypospadias is chordee and how severe is the chordee or the curvature of the penis. First step in any hypospadias surgery is to correct the curvature fully- chordee correction and then only plan the urethroplasty. Chordee correction surgery is hence the first step in any hypospadias repair procedure. Chordee correction is a step wise procedure
- Degloving: sometimes its just the skin on the underside of the penis which causes shortening and curvature. In such cases, just degloving can lead to release of the chordee.
- Even if there is a minor chordee (less than 20-25 degrees), Tunical plication can be done to completely correct chordee in such cases and a single stage surgery can be done.
- Division of the urethral plate: If after degloving there is still more than 30 degrees chordee, it is better to divide the urethral plate and plan for a two-stage surgery.
- Corporotomies: If the curvature is still significant, then either small fairy cuts can be given or a format deep corporotomies can be done to correct the curvature fully.
- Dermal Graft: In some severe cases, the underside of corpora may be really short and we may need to augment the ventral side with a dermal graft. This can be taken from inguinal region.
Overall, chordee correction is an art and cases with severe chordee must be operated by only those expert hypospadias surgeons who have been doing such cases regularly and have the necessary experience and training to give good results with least complications.
About Dr A.K. Singal and Hypospadias Foundation
Hypospadias foundation is amongst the most reputed and one of the best hospital centres for hypospadias repair surgery in India and the world. The single most important thing in having good results for hypospadias is the “decision making”- which is to do the following things right:
- Choose the right time to do the surgery
- Choose the right preparation for surgery
- Choose the right technique for surgery
- Choose the right length of catheter stay and post-op care
Over the years and after 15 years and 2000+ hypospadias surgeries, Dr A.K.Singal has refined the techniques and procedures for hypospadias repair, leading to better results and lesser complications. Children and adults from all over Mumbai, India and other countries come to Hypospadias Foundation at Navi Mumbai, India for the best treatment and care for hypospadias.
At Hypospadias Foundation, Dr A.K.Singal is an expert and top pediatric urologist in India. Every year he treats children and adults with hypospadias in India and he also travels to Bahrain for performing genitourinary surgeries in children from Gulf, Middle East and African countries.
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