Dr. A.K.Singal, Author at Hypospadias Foundation

December 12 2014

Distal Penile Hypospadias in a child: Single stage repair surgery video using TIP urethroplasty (Snodgrass repair)

Distal penile hypospadias is the most common type of hypospadias in children. The urethral opening is located on the underside of penis but in last 1/3 of the penis. While some of the distal hypospadias may have an associated bend in penis called Chordee, most of the distal hypospadias may not have a chordee. There are many types of hypospadias surgery techniques described and the hypospadias surgeon selects the type of repair depending on the anatomy.

The key factors in deciding the repair are:

Severity of Chordee
Severity of hypospadias
Quality of urethral plate
Experience of the surgeon

Snodgrass repair or Tubularised incised plate urethroplasty was described by Dr Warren Snodgrass in 1992 and relies on using the natural tissues of penis on the underside for making a new urinary passage. The basic concept is midline incision of the open urethra from the urinary opening till the head of penis. This expands the urethral plate and allows it rolled into a new urethral tube which can heal very well.

The critical steps are:

Degloving of the penis: Incisions are marked preserving the urethral plate and all the penile skin is taken down to correct chordee. This step doesn’t harm the nerve and blood supply of penis as that runs deep inside the penis.
Artificial erection test: After applying a tourniquet, artificial erection test is done to check for any curvature (chordee). If there is no curvature, urethroplasty can be started.
Chordee correction: In most of the children with distal hypospadias, degloving alone releases the bands on underside of the penis and chordee gets corrected. In some children with hypospadias, chordee correction may be needed. This can be done by either putting a stitch – Tunica albuginea plication or by dividing the urethral plate. Urethral plate division is needed only in patients with severe chordee. But once the urethral plate is divided, TIP urethroplasty can’t be done, other types of repairs have to be planned.
Glans wings: Urethral plate is dissected into glans, creating glans wings on either side which are mobilized deep. Midline urethral plate incision (TIP incision) is given to expand the urethral plate and then urethra is closed with a fine absorbable suture such as PDS or vicryl to construct the new tube. The sutures are taken in a subepithelial fashion to invert the mucosa.
Second layer coverage: If there is good corpus spongiosum around urethral plate, it is mobilized for spongioplasty to provide security from urethral fistula. We also routinely use Dartos flap to cover the urethroplasty and prevent complications such as urethral fistula.
Glansplasty and skin coverage: Glans wings are closed with absorbable sutures and excess foreskin on the top is divided in midline and brought ventrally for complete skin coverage. Midline closure is achieved after excising excess skin so that a pleasing cosmetic outcome can be sought.
Dressing and catheter: Though lot surgeons use bulky dressings after hypospadias surgery, we use mostly a Tegaderm (transparent plastic wrap) followed by a soft gauze dressing. The catheter is tied to the glans stitch and allowed to drip urine into the diaper.

Follow-up and care after hypospadias repair surgery with TIP urethroplasty:

Most of the children are discharged by the evening of hypospadias surgery. Antibiotic syrup, pain killers and antispasmodic medicines are given for a week’s time. The parents are taught double diaper care and we call the children for follow-up after 5-7 days for removal of dressing and catheter at the same time. The hypospadias dressing is removed in clinic itself and the parents are advised to apply an antibiotic ointment on the penis for 2-3 weeks. Bath can be given as soon as the dressing is removed. We call for follow-up two weeks after catheter removal and after 3 months if everything is healing well.

About the author:

Dr A.K.Singal is a renowned Pediatric Urologist and Hypospadias Surgeon practicing in western india in area of Mumbai, Navi Mumbai and Thane. He is counted as one of the best hypospadias expert surgeons in the world and every year manages more than 200 kids and adults with hypospadias. He started Hypospadias Foundation in 2008 and Hypospadias Foundation remains the world’s only organisation dedicated to children with Hypospadias. Children from more than 20 countries travel every year to India to consult for hypospadias treatment under his team’s care.

Dr A.K.Singal during Hypospadias surgery

He is available at the following clinics : Clinics and Timings for Dr A.K.Singal

Watch video of Distal penile hypospadias repair surgery video by Dr A.K.Singal

Watch video of Single stage repair surgery of severe hypospadias by Dr A.K.Singal

Watch Video of repair of glanular hypospadias with chordee by Dr A.K.Singal

To send an enquiry to Dr Singal’s team please fill up this form:

Contact form for Hypospadias enquiry

Contact Form for Hypospadias Foundation

Please fill all clinical details and upload pictures and clinical summaries (if available)

November 11 2014

Good results of hypospadias repair surgery in adults even after previous failed repairs

Besides 100,000 kids born in India every year with hypospadias, there are an estimated 5-10 lakh adults living with either unoperated hypospadias or failed hypospadias having complications of Hypospadias surgery. These can be minor issues such as urethral fistula, chordee or suboptimal cosmetic results but a significant number may have major issues such as completely failed hypospadias, urethral diverticulum, hairy urethra, urethra stricture etc. Unable to come to terms with penile deformity, they do not get any hope or assurances from adult urologists or plastic surgeons as this may not be the area of primary interest or dedication for them.

Mr Rajveer Singh, 30 years old man, had a midpenile hypospadias with chordee and was operated by a plastic surgeon in Hissar Haryana 2 years back. After surgery, there was a breakdown of hypospadias repair and he was still passing urine from underside of penis. He was still having a downward curvature of penis (chordee) even after this surgery. Also he had seen hair growing out of urinary opening over last few months. He was very worried as he wanted to get married, hence he wrote to us asking for help. We wrote back asking for detailed pictures on email which would help us in understanding his clinical condition and hypospadias deformity. Finally, we called him to see us at Hypospadias Foundation in Kharghar, Navi Mumbai. He took a flight from Delhi to Mumbai and landed up in my Hypospadias clinic on a Monday evening. On examination, he had a urinary opening much below the head of penis in midpenile region and also a couple of holes (urethral fistula) from where he was leaking urine. More importantly his penis still looked bent due to uncorrected chordee. Lastly the cosmetic outcome was really bad with tags of skin here and there and we could see hair coming out of his urethra due to previous failed improper hypospadias surgery. This results when an undertrained hypospadias surgeon uses hairy penile skin for urethral reconstruction. We counselled Rajveer regarding the surgical plan the first step of which would be excision of all unhealthy skin tissue on underside of penis, chordee correction (straightening of penis) and then decide for the type of hypospadias repair in operation theatre. This would be either a single stage repair using a local flap from hairless penile skin or a staged repair using a buccal mucosa graft. In staged buccal mucosa graft – we first excise all unhealthy tissue and scars of failed hypospadias repair, then take a thin lining from inside of lower lip or cheek and then place it as a graft on underside of penis. Once this graft gains local blood supply from penis tissue, we roll it into a urethral tube typically after 6 months of first stage. We always keep buccal graft as the last option in failed hypospadias as that essentially means multiple surgeries. Hence, we attempt to do a single stage flap repair whenever feasible even in failed hypospadias and hence we shared this intent with Rajveer.

Rajveer was taken up for surgery the next day under spinal anesthesia and first a cystoscopy was done. It showed normal urethra beyond midpenile region and unhealthy scarred hairy urethra with fistulae in the distal penile region. We excised all the unhealthy tissues and then checked for chordee. There was still 30 degrees bend in penis which needed correction by a 12 O’clock non-absorbable stitch on the top side of penis. On rechecking with artificial erection, there was no chordee now. After chordee repair was satisfactory, we analysed the penile skin on the right side of penis. We could see an island of hairless skin which was possibly remnant of foreskin (prepuce). We designed a long flap from this with very good blood supply from the underlying dartos tissue. This flap was used in an onlay fashion to repair hypospadias in a single stage. Finally head of the penis (glans) was also repaired and a catheter was placed to drain urine till the whole repair healed. Rajveer went back to his home town in Haryana after 3 days of surgery and then we arranged for one of my surgeon colleagues in Hissar (Dr Vivek Gupta) to help with post hypospadias surgery care. The catheter was removed on day 14 since it was a major hypospadias reconstruction. Rajveer passed urine well and but the full healing of the penis took about 4 weeks. The final cosmetic result was excellent when he sent the pictures via email. He visited us recently almost 3 months after surgery, the penis looked well healed and he is passing urine well from the tip in a good stream. His erections are straight and he is now looking forward to get married. The only question is whether he will invite me for his wedding or not and if he invites, how will he introduce me.

When such complex failed cases do well after hypospadias treatment at Hypospadias foundation, it makes us very happy. We feel our goal of starting the foundation in Nov 2008 has been fulfilled. Last six years have been a long and exciting journey but is has been a very challenging time. When we started we never knew the burden of problem was so high. Along the way we have been privileged to be a part of lives of more than 600 kids and adults with Hypospadias from all over India and some countries abroad. Almost 25% of those receiving treatment at Hypospadias Foundation, have been patients with failed hypospadias who received surgery elsewhere. Though initially we started only with management of hypospadias in children but we realized that there is huge gap when it comes to treatment of hypospadias in adults. Along with Dr Manish Dubey, my close friend who is an adult urologist we are able to offer good care and success rates in adults and failed hypospadias.

In last three years, Hypospadias Foundation has welcomed many patients from many other states and countries such as Nepal, Bangladesh, Greece, Afghanistan, Iraq, Saudi Arabia, UAE-Dubai, Oman, Great Britain (UK), USA, Nigeria, Tanzania, Kenya, Congo, Zambia and this number continues to grow attesting to our devotion to the field of Hypospadias. Within India, kids and their families have travelled for treatment of hypospadias from Assam, Kolkata, Orissa (Puri, Bhubhaneshwar), Ranchi, Chattisgarh (Raipur, Katni), Gujarat (Ahmedabad, Surat, Baroda, Gandhinagar), MP (Indore, Bhopal), Himachal, Delhi, Haryana (Hissar, Rohtak, Panipat), Rajasthan (Bikaner, Jaipur, Jodhpur), Maharashtra (Jalgaon, Pune, Aurangabad, Nasik, Nagpur, Parbhani, Dhule, Solapur, Kolhapur, Ahmednagar, Ratnagiri), Uttar Pradesh (Lucknow, Allahabad, Meerut), Goa, Andhra Pradesh (Hyderabad, Belgaum, Guntur), Uttarakhans (Dehradun), Jammu, Kerala (Cochin), Tamilnadu (Chennai, Salem, Coimbatore) and Punjab (Chandigarh, Ludhiana and Patiala).

About the author:

Dr A.K.Singal is a Pediatric Urologist and Hypospadiologist practicing in western india in area of Navi Mumbai and Thane. He is counted as one of the best hypospadias expert surgeons in the world and every year manages more than 200 kids and adults with hypospadias. He is available at the following clinics :

Clinics and Appointments for Dr Singal

To send an enquiry to Dr Singal’s team please fill up this form: Contact Dr A.K.Singal

Watch video of Single stage repair surgery of severe hypospadias by Dr A.K.Singal

Watch video of repair of glanular hypospadias with chordee by Dr A.K.Singal

Watch video of Distal penile hypospadias repair surgery by Dr A.K.Singal

Contact Form for Hypospadias Foundation

Please fill all clinical details and upload pictures and clinical summaries (if available)

August 08 2014

Twins from Greece undergo successful surgery for severe hypospadias in Mumbai, India

Across the borders for Hypospadias

Hypospadias is one of the most common congenital anomalies affecting more than 4,00,000 newborn babies every year across the globe. The problem is not restricted to any particular country or race. Every year, our team at Hypospadias Foundation lead by Dr A.K. Singal manages kids with hypospadias from across India and also from other countries such as Nigeria, Kenya, Iraq, Bangladesh, USA and recently Greece.

Well, the kids from Greece were a whole different story. Though originally from Greece, their father Ioannis Padadatos was employed with a company in Delhi. Master Konstantinos and Spyridon Papadatos, twin babies were born in Delhi to Maria and Ioannis were noted to have hypospadias at birth. The hypospadias was relatively severe in both the children and had associated chordee. The urethral opening was near the scrotum (testis) called Penoscrotal hypospadias. Parents were very hassled as they had never heard of the condition before and now both their newborn babies had severe variety of hyposapdias. Dissatisfied with the information given by pediatricians, pediatric surgeons and urologists in Delhi, they took up to internet for more information. They contacted Dr A.K.Singal, Pediatric Urologist & renowned Hypospadias surgeon who regularly writes articles at www.hypospadiasfoundation.com . Though they had visited the multiple doctors in delhi, what reassured them was the blogs written by dr A.K.Singal about his experience with children who had hypospadias.

After exchange of a few emails, Maria and Ioannis travelled all the way to Mumbai when the babies were 6 months old, in Nov 2013 to consult Dr A.K.Singal at Fortis Hospital in Vashi. Since the right age of surgery for hypospadias is 6 – 15 months, the parents elected to get the surgery done as soon as possible. After the blood tests, the parents again came to Mumbai in December to get the surgery done for both the kids. Master Spyridon underwent surgery on a Monday while Konstantinos underwent surgery on Tuesday. Though both had severe hypospadias and the parents were counseled that a two staged correction may be needed, the whole hypospadias surgical correction was performed in one stage using an Onlay Island Flap urethroplasty of which Dr Singal is an expert. The correction of penile curvature (chordee correction) and formation of new urinary tube (urethroplasty) were all performed in one stage.

After one more day post-surgery in Mumbai, the family travelled back to Delhi and kept in regular touch with Dr Singal via email. Dr Singal visited them one week later in Fortis Hospital in Delhi while attending a conference. Finally the catheter (urinary pipe) was removed after ten days of surgery and babies passed urine in good thick stream signifying a successful outcome in one stage. Now almost nine months after hypospadias surgery, both the babies are doing extremely well.

The family has now shifted to Doha, Qatar but they have taken a lot of India with them and most of all fond memories. We at Hypospadias Foundation are very happy to see the kids grow well and pass urine from a normal opening.

Dr Singal adds “With the advances in instruments and sutures plus better surgical techniques, we are able to do single stage correction for even severe hypospadias in most cases. Rarely we need second surgery and that too if there are complications in the first hypospadias surgery. I am happy that Maria and Ioannis trusted us for management of their children for hypospadias. They came with full faith and trust and that made my job so much easier. I will always remember their family and their beautiful kids. It was indeed a joy meeting them and knowing them. Sometimes I wonder as a hypospadias surgeon what kind of leap of faith the parents must take to travel in an unknown country to an unknown doctor and trust him/ her with the lives of their little ones. I truly appreciate their courage and faith.”

Contact Form for Hypospadias Foundation

Please fill all clinical details and upload pictures and clinical summaries (if available)

August 08 2014

Post-operative instructions and home care after hypospadias repair surgery

Hypospadias surgery is a delicate, skillful and complicated surgery. The good thing about hypospadias treatment is that young babies heal very fast and become well within a week to ten days after the hypospadias repair. Fortunately, unlike adults, the children do not think about pain. They live their life happily soaking in, everything moment to moment. Adults on the other hand think and anticipate pain too much hence they land up having more pain. It is the anticipation of the pain which is worse than the pain itself.

That being said, here we have tried to give detailed post hypospadias repair instructions for the parents and patients so that they can understand the care which needs to be taken after hypospadias surgery. Please note that these are generalized instructions after hypospadias surgery and there will be some variations on a case to case basis and it is best to discuss with your hypospadias surgeon for other details.

Diet: Children can often be fed 2-3 hours after hypospadias repair if the surgery was done under sedation and caudal epidural anesthesia. Some complex or failed hypospadias may require general anesthesia for surgery and these kids are kept empty stomach for 3-4 hours after surgery.
Urine passage: In almost all the hypospadias repairs, there is urinary pipe called catheter which is left across the hypospadias repair site. This goes into the bladder and drains drops of urine continuously. It is generally removed after 5-10 days by the hypospadias specialist depending on the type of the repair.
Diaper care: Post hypospadias treatment babies are kept in double diapers till the time the catheter is there. If the child is more than 6-7 years of age, then diapers may be difficult to maintain- hence we prefer to use a urine bag for drainage of urine. We ask the parents to make a hole on the front side of inner diaper and bring out the catheter to drain into the outer diaper. This way the inner diaper is changed only when the child passes motions and hence remains dry. Outside diaper is changed whenever it is full of urine.
Hypospadias Dressing care: At the end of hypospadias surgery, we place a soft gauze roll dressing on penis to give some support to the healing penis. There may be minor bleeding into the diaper on and off for first 3-4 days which is nothing to worry about. The hypospadias dressing sometimes becomes loose and comes out. If this happens within first 2-3 days, then we change the hypospadias dressing. If it happens later, we just remove the dressing and leave the wound open.
Discharge after hypospadias surgery: Most of the children who have a simple primary hypospadias are discharged the same day of surgery by evening- daycare hypospadias surgery. Children who are traveling from far may come the night before to hospital and stay for a day or two after surgery as well. Children who have undergone a failed hypospadias or a complex surgery are kept in hospital for 2 nights after surgery also for antibiotic injections or pain relief etc.
Pain relief: We prescribe an oral syrup of analgesic medicine mostly a combination of ibuprofen and paracetamol for first few days after surgery. This ideally should be given post feeds and not on empty stomach. We also give a medicine called oxybutynin which is an anticholinergic and prevents bladder spasms (painful bladder contractions due to catheter).
Medications: A broad spectrum antibiotic such as cephalexin is also prescribed to prevent infections along with an antacid medicine such as Lansoprozole for the first few days.
Activity, walking, playing within the house is allowed even the day of surgery by evening but we ask the parents to make sure that the child does not use cycle or any toy on which straddling is needed. Child can sleep on his tummy if he likes to sleep that way. Double diapers prevent too much compression of the hypospadias repair site.
Visits with doctor: We like to see the patients on day 5 after surgery for removal of dressing and for some minor hypospadias repairs we remove the catheter also at the same time. If its moderate or severe hypospadias surgery, we generally remove the catheter after 7-10 days and hence the catheter is removed on second visit then.
Bathing: Once the dressing is out on day 5, the child can be given a short warm tub bath. We ask parents not to use any cotton or cloth for drying the area of hypospadias repair surgery as fibers can stick to the raw area. It is better than after drying the rest of the body the diaper is put on directly and that will dry the area.
Ointments on penis: We advise putting a broad spectrum antibiotic ointment such as neosporin locally on the penis at each diaper change so that it prevents infection and also protects the raw area from sticking to the diaper.

We hope this little primer on care of children after hypospadias surgery helped you. Please feel free to get in touch with us if you need any further information. We hope and pray that your little kid becomes better soon and recovers well from hypospadias surgery.

About the author:

Dr A.K.Singal delivering his talk at ESPU

Dr A.K.Singal is one of the best hypospadias surgeons and Pediatric Urologists in India. He practices in Navi Mumbai, Thane and Mumbai area of India. Dr Singal believes in giving as much information to parents and families as possible about surgery, pre surgery and post surgery course. It helps the parents to be fully informed as he says in his own humorous way- “it decreases my stress and time per consult”

In case you have a child with hypospadias, you can contact him at the following places:

1. MITR Hospital & Hypospadias Foundation

74-90, 1^st Floor, Above IDBI Bank, Chaturbhuj, Shilp Chowk

Sector-21, Kharghar, Navi Mumbai- 410210

Mon & Fri: 5:00-6:30pm, Tues: 12-1pm, Appointments: +91-22-27743558/4229 & 09324180553

2. Fortis Hospital, Mulund

Mulund Goregaon Link Road, Mulund, Mumbai – 400078

Wed & Sat: 4:00pm-5:00pm, Appointments: +91- 22- 43654365; 67994185

3. Jupiter Hospital, Thane

Wed & Saturday, 2:00pm-3:00pm, Appointments: +91-22-21725563/ 55

4. MGM’s New Bombay Hospital, Vashi.

Sector-3, Vashi-400703, Navi Mumbai

Mon, Wed & Fri: 7:00-8:00pm, Phone: +91-22-61526666/ 6675/ 6607

5. MITR Clinic, Vashi

C1/8, Sector- 2, Opp. Green City, Vashi, Navi Mumbai

Tue & Sat: 7:00pm-8:00pm, Appointments: +91-22-65163816 & 9324502572

6. Fortis Hiranandani Hospital, Vashi

Miniseashore road, Sector-10, Vashi, Navi Mumbai

Tue & Sat: 6:00pm-7:00pm, Appointments: +91-22-39199200, 222

Email address: arbinders@gmail.com

Websites:

www.pediatricurology.in, www.hypospadiasfoundation.com, www.mitrhospital.com

Youtube channel: www.youtube.com/pedurohypospadias

Videos:

Single stage repair of severe hypospadias

Interview: Dr Singal speaks about Hypospadias

Contact Form for Hypospadias Foundation

Please fill all clinical details and upload pictures and clinical summaries (if available)

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