About Hypospadias Archives - Page 2 of 5

March 03 2024

Single stage hypospadias repair in a boy after multiple failed hypospadias surgeries

“Mast SP, a 15-year-old male from South Africa, is a case of failed hypospadias repair, having undergone four unsuccessful surgeries elsewhere in the past. Despite previous attempts, the desired result of hypospadias repair was not achieved. He presented to us with complaints of spraying of urine with residual chordee. On clinical examination, we found that the meatus was located at the coronal region. The penis was small with flat glans. He was planned for cystoscopy to assess the status of the native urethra, and redo hypospadias surgery was planned in a single stage or in two stages depending on the cystoscopy findings, addressing the challenges of hypospadias repair in a boy

1. Clinical picture showing coronal meatus.

Cystoscopy showed normal urethra. Since the majority of the urethra was normal, we planned for single stage repair, focusing on hypospadias repair in a boy. We chose to proceed with single stage distal oral mucosa inlay graft urethroplasty.

Chordee assessment was done at the start of surgery, and the patient did not have chordee, hence degloving was not done. A midline incision was given in the urethral plate to assess the quality of the urethral plate. There was no scarring in the urethral plate. Since the urethral bed was healthy, we planned to place an oral mucosa inlay graft and perform single stage urethroplasty.

2 a & b. Clinical picture showing the marking of the incision and chordee assessment.

Oral mucosa graft was harvested from the upper lip to perform hypospadias repair in a boy. The graft was defatted and sutured at the urethral bed using 5-0 vicryl. The graft was sutured at the edges of the urethral plate and was quilted in place using 5-0 vicryl sutures. Following inlay graft placement, glans wings were widely mobilized. Urethroplasty was done using 5-0 vicryl stitch, first layer was continuous subcuticular inverting sutures. Second layer was closed using local tissues. Local flap was harvested from the left side and sutured over the urethroplasty as a waterproofing layer using 5-0 vicryl. Glans wings were widely mobilized and distal urethroplasty along with glansplasty was done using 5-0 vicryl.

3 a & b Picture showing site of oral mucosa graft harvest i.e upper lip and oral mucosa graft, it has been placed and quilted in the urethral bed.

4 a & b: Distal urethroplasty completed and local flap harvested from the left side.

5 a & b: Local flap sutured over the urethroplasty, and second picture shows completion of the entire repair.

After undergoing hypospadias repair in a boy, the patient had a per urethral catheter and suprapubic cystostomy (SPC). Dressing change was done on postoperative day 4 followed by operated site inspection on every 4th day. Per urethral catheter was removed on postoperative day 21 and SPC was removed on postoperative day 22.

6. Picture showing status at post operative day 15 and second picture shows urine stream after catheter removal.

Post catheter removal, he was passing urine in single straight stream with no leak. Patient was started on meatal dilatation using meatal dilator with mild steroid ointment for 3 months.

Testimonial from the boy’s father in his own words:

We are from South Africa. We got reference of Dr. Singal from a website, post which I got an appointment. Post which they did a proper evaluation and told that he had to undergo a redo hypospadias repair. Based on the evaluation, he had to do redo surgery for hypospadias repair in a boy. We came here on 22nd of December, procedure was properly explained to us. The surgery went well, post care after the surgery was also extremely good. Total support staff, hospital staff took care of my son very well. After the surgery, the discharge process was very fine, post care after discharge was also very good. The steps were properly explained. Today we are finishing the treatment and going out of India to South Africa. From my experience, the overall procedure was very good and extremely satisfying.

Single Stage Hypospadias Repair In A Boy After Multiple Failed Hypospadias Surgeries

Failed hypospadias repair refers to a situation where the initial surgery to correct hypospadias was not successful. Inspite of the best efforts by the surgeon the complications may happen because every healing of every hypospadias patient is different. We do not know the exact reason for complications after hypospadias surgery but here are some factors which may contribute to post-surgery complications:

Severity of hypospadias: Severe hypospadias repair is more complex and more challenging than mild hypospadias. Total healing time in hypospadias is 3- 4 weeks and it is longer in severe hypospadias. To minimize the risk of complications in severe hypospadias repair, the entire repair may have to be done in 2-3 stages.
Surgical technique: Different surgical techniques have varying success rates, and the choice of technique can impact the outcome. The choice of technique depends on the type of hypospadias, degree of chordee, glans diameter etc. An expert hypospadias surgeon will choose the best technique after considering all the factors because no two techniques are the same, and no two hypospadias are the same.
Experience of the surgeon: The experience of a surgeon is an important factor for successful hypospadias surgery. Centre performing more than 50 surgeries per year will have lesser complications compared to the other centres.
Wound healing: Wound healing is an important deciding factor in complications after any surgery. In hypospadias, wound healing is very slow in adults as compared to children. This may be because of decreased cell turnover with age, a weakened immune system, and reduced blood flow. And if they have any preexisting co-morbid illnesses then healing is slower, with a higher risk of complications.
Age at surgery: The best age to undergo hypospadias surgery is between 6 and 18 months of age. If not done at this age, it should ideally be done by 5 years of age. Parents are sometimes unable to get the surgery done within 5 years of age, and these children, when they reach adulthood, realize that they need surgery to correct the hypospadias. Outcomes in later age are little inferior to childhood hypospadias surgery but still possible. Adults with hypospadias need not lose hope because it’s better late than never. At Hypospadias Foundation, we have been able to achieve good outcomes with cosmetic result with a success rate of more than 90%, even in adults after multiple previous failed surgeries.
Underlying medical conditions: Obese or overweight adults, smokers, poor nutritional status, and diabetes are some of the conditions that can lead to slow healing. Overweight patients or diabetics can develop insulin resistance, causing poor healing. Smokers, nutritional deficiencies, etc. can cause decreased blood flow to the operated site, associated with decreased collagen production, which in turn causes slow healing.

Impact and Considerations after failed hypospadias repair:

A failed hypospadias repair can have both physical and emotional consequences for an individual with adult hypospadias and for parents of kids suffering from hypospadias. Complications that can occur after hypospadias repair are:

Urinary problems: difficulty in urinating, spraying of urine (glans dehiscence), urine passage from multiple holes (fistula), pain in urinating, or urinary tract infections, swelling pf penis during voiding (diverticulum), problems with ejaculation, post void dribbling,
Residual chordee (curvature): The penis may remain bent, affecting sexual intercourse and, in turn, leading to sexual dysfunction.
Cosmetic appearance: The meatus may be at a slightly lower level than normal. This may be disturbing for some individuals. In this case, there will be no problems in passing urine, and it is merely the way it looks different from others.
Psychological impact: As a parent, you may feel helpless and angry after a failed hypospadias. Failure of hypospadias surgery can cause feelings of anxiety, frustration, suicidal tendency, and low self-esteem in an adult. At certain times, adults may need pre- surgery counseling to reduce anxiety and stress. By improving your communication with your doctor and understanding the risks and benefits of surgery, you are more likely to be satisfied with the outcome.

Seeking Help:

If you or someone you know has a failed hypospadias, it’s crucial to seek professional help from a urologist specializing in pediatric urology or hypospadias. They can assess the situation, discuss treatment options, and provide guidance and support throughout the process. Even after previous unsuccessful repairs, there is more than 90% chance that with an expert hypospadias surgeon, the complications can be managed, and your hypospadias can be fully cured.

About Hypospadias Foundation

At Hypospadias Foundation, we get adults and children from all over the world in search of treatment for hypospadias. We provide support and information for children, adults, and their families affected by hypospadias. Dr Singal and Dr Shenoy are deeply devoted to creating awareness and helping patients get the right treatment and best outcomes for hypospadias. Children and adults from more than 25 countries visit Hypospadias Foundation in search of treatment for hypospadias.

Dr A K Singal is a highly experienced surgeon and is regarded as the best hypospadias surgeon in India and in the world for treating children and adults with hypospadias. If you are looking for a highly skilled and experienced pediatric urologist and hypospadias surgeon for yourself or your child, then Dr Singal is an excellent choice.

Dr Ashwitha Shenoy is an expert pediatric surgeon with a special interest in pediatric urology and hypospadias. Dr Singal and Dr Shenoy’s collaboration allows them to offer advanced surgical techniques and comprehensive care for patients.

For appointment kindly contact us at the contact details given below.

MITR hospital & Hypospadias Foundation, Kharghar, Navi Mumbai, India – Tue/Saturday 4:00pm-6:00pm, Call for appointments: +91-9324180553 (whatsapp), +916262840940, +916262690790 Or email us at hypospadiasfoundationindia@gmail.com

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March 03 2024

Why does hypospadias occur?

Why does hypospadias occur?

Hypospadias is a congenital abnormality of the penis with an incidence of 1 in 150 live births. In hypospadias, the urinary opening (peehole) is in an abnormal position on the underside of the penis. As a parent of a child with hypospadias, you may wonder what causes hypospadias. Infact this is the most common question which parents ask us in the clinic- Why did my child develop hypospadias?

The exact cause for hypospadias is not known but there are various factors which can increase the risk of hypospadias in your baby. This blog is to help you understand the probable factors which may lead to hypospadias in your baby boy.

Genetic factors:

Family history: While 90-95% of hypospadias are isolated cases, 5-10% of them do run in families. If the father or anyone in first degree family has hypospadias, then the risk of having hypospadias in subsequent male children increases.

Environmental factors:

Maternal exposure to pesticides or herbicides in pregnancy may cause hypospadias.

These pesticides are known to be endocrine disruptors, they interfere with the androgen and oestrogen signalling pathways during genital development, hence causing hypospadias. This is a hypothesis and studies are still under process to clearly link exposure of pesticides to occurrence of hypospadias.

There have been studies showing higher risk of hypospadias due to plasticisers in the single use plastic bottles. The chemicals here act as male hormone blockers and interrupt development of penis, hence causing hypospadias.

Hormonal exposure in pregnancy:

During pregnancy, certain hormones may be advised for the mother to decrease the chance of preterm labour or miscarriage. This is common after invitro fertilization (IVF) conception, twin pregnancy and in precious pregnancies. Carmichael reported that the use of progesterone to prevent early pregnancy loss was associated with risk of developing moderate to severe hypospadias.

Maternal factors:

Maternal pre pregnancy obesity with a BMI>30 has been associated with 1.3-to-2-fold increased risk of hypospadias compared to other women who had normal weight in the pre pregnancy period.

Maternal nutrition is very important for the development of fetus. Folic acid supplementation in the pre conceptional period is necessary to prevent various congenital anomalies. Study conducted by Mavrogenis et al showed that folic acid supplementation early in pregnancy was associated with low risk of hypospadias.

Hypertension in pregnancy and usage of anti-hypertensive medicines are associated with development of hypospadias in the fetus. Untreated hypertension has an odds ratio of is 2.1 and anti-hypertensive usage in pregnancy has an odds ratio of 1.6 for development of hypospadias. The cause for this is most likely because of reduced placental perfusion in hypertension.

It has been hypothesized that the maternal use of estrogen and progestin may cause hypospadias because of interference with fetal androgen production or action. Several other medications have been associated with moderate to severe hypospadias. These include ibuprofen (odds ratio 1.2), Venlafexine(odd ratio 2.4), proton pump inhibitors(odds ratio 4.4) and clomiphene citrate(ovulation induction agent with odds ratio 1.9)

Birth factors:

Infants with hypospadias are most likely to be born preterm, low birth weight or small for gestational age. These are more strongly associated with severe hypospadias than the milder forms of hypospadias. Placental dysfunction may fail to stimulate fetal androgen production which is necessary for urethral closure. It also causes reduced transfer of nutrients to the fetus causing growth restriction. Placental dysfunction and androgen deficiency in early pregnancy are known to cause intrauterine growth restriction and hypospadias.

The most important message here is that it is not the fault of the mother or father which can cause hypospadias in their child. The above-mentioned factors may increase the risk of hypospadias but that is not always true. A pregnant woman should take care of her health and avoid exposure to chemicals as much as possible. She should maintain a healthy diet, get good sleep, and avoid stress. Even if your child has hypospadias inspite of all the extra care, do not worry. Hypospadias is a condition that can be easily corrected by surgery by an expert pediatric urologist or a surgeon who specializes in hypospadias repairs.

At hypospadias foundation India, we have been blessed to treated families having twins or two brothers with hypospadias. We also have cases where father had hypospadias and then their child had hypospadias. Some of these parents themselves did not achieve good results in their day and age but now with latest techniques which we use at Hypospadias Foundation, the results which their children get after hypospadias repair surgery are very good.

In current era, success rate of hypospadias in first surgery itself is more than 95%. At hypospadias foundation, we treat hundreds of children and adults with hypospadias every year, both the ones which are primary or the ones where the previous repair has failed. If your child has hypospadias, do visit us, or consult us online to get the best hypospadias treatment for your child. Every child deserves the best and we are here to support you to give the best care to your child.

Fill up contact form: https://www.hypospadiasfoundation.com/contact/

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August 08 2023

Dr A.K.Singal presents his work at Hypospadias World Congress at Childrens Hospital of Philadelphia, USA

Dr A.K. Singal was an invited speaker at the Hypospadias World Congress, held at the Children’s Research Center at Children’s Hospital of Philadelphia, USA, between 30th October 2019 and 1st November 2019. Dr. Singal presented four papers on hypospadias treatment and moderated scientific sessions during the conference. His groundbreaking contributions further solidify his reputation as an expert in the field of pediatric urology, driving innovative advancements in hypospadias surgery and treatment.

The conference saw participation from more than 150 pediatric urologists and hypospadias specialists from across the world. The conference solely focussed on hypospadias. Various aspects of hypospadias were discussed such as etiology, diagnosis, hormonal tests and supplementation (testosterone injections), surgery techniques and complications/ results of hypospadias surgeries.

Dr. A.K.Singal

Dr. Singal with Dr. Long & Dr. Zaontz

Dr. Singal presented the following lectures and papers in the World Congress:

Buccal inlay graft for failed hypospadias- Dr Singal showed technique of buccal (oral) mucosa graft inlay surgery and its results in failed hypospadias cases.
Considerations in adult hypospadias repairs- Adult hypospadias are difficult to manage especially if the surgery done in childhood has failed. Dr Singal showed innovative surgery techniques for such adult hypospadias cases for best outcomes.
Reimagined Byar’s flaps for staged hypospadias repairs- For hypospadias with severe chordee, it is important that the penile curvature gets fully corrected in first stage and then second stage surgery is done for bringing the urethra to the tip of penis. In expert hands the results of two stage surgery for hypospadias with severe chordee is very good. Dr Singal showed finer nuances of surgery to achieve best results to the audience.
Parental Awareness survey for families with hypospadias: Families of children or adults with hypospadias are often not fully aware of the extent of disease and what it means in the long run. Dr Singal and his team conducted a study of 150 families to understand about their concerns about hypospadias and their knowledge level about the disease/ surgery.

Overall the three-day conference resulted in great mutual exchange of ideas and also helped younger generation of surgeons learn from eminent faculty from all over the world.

Fill up contact form: https://www.hypospadiasfoundation.com/contact/

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December 12 2022

Hypospadias Guide for Pediatricians and Healthcare Professionals

Hypospadias Foundation starts Clinic for Hypospadias Treatment & Surgery in Bahrain

The Hypospadias Foundation is an organization dedicated to disseminating thorough and credible information and providing personalized medical care for patients with Hypospadias and DSD. Caring for children with hypospadias/DSD requires a lot of commitment from both the family and the healthcare team managing these children. Our Hypospadias Guide for Pediatricians and Healthcare Professionals offers invaluable resources to support effective care and treatment strategies.

What is hypospadias and what are the types of hypospadias?

Hypospadias is a congenital condition where the opening of the urethra (meatus) is on the underside of the penis rather than on the tip. It may be associated with abnormal curvature of the penis (chordee). The different types of hypospadias, including glanular, coronal, distal penile, mid-penile, proximal penile, penoscrotal, scrotal, and perineal hypospadias, are vital knowledge for pediatricians and healthcare professionals navigating this condition. Explore our comprehensive Hypospadias Guide for Pediatricians and Healthcare Professionals for in-depth insights into diagnosis, management, and treatment strategies.

Hypospadias Guide for Pediatricians and Healthcare Professionals

How is Hypospadias diagnosed?

Hypospadias should be suspected in a newborn when the prepuce is incomplete, the meatus is on the underside, and there is a bent penis (chordee). Ideally, a pediatrician should be able to clearly diagnose hypospadias clinically at birth. In some cases, there may be doubt, especially in minor hypospadias. In such cases, it may be good to consult a pediatric urologist or a surgeon around 3-6 months of age. Explore more insights on diagnosis and management in our Hypospadias Guide for Pediatricians and Healthcare Professionals.

When do you suspect DSD?

DSD is suspected when the hypospadias is severe (Scrotal or perineal), when hypospadias is associated with a small size of the penis (microphallus), or when the hypospadias is associated with one-sided or both-sided undescended testes. In such cases, investigations in the form of karyotyping and hormonal evaluation are necessary. Pediatricians and healthcare professionals can find detailed guidance on identifying and managing such cases in our comprehensive Hypospadias Guide.

When should a child with hypospadias be referred to a pediatric urologist or a pediatric surgeon?

In children with isolated hypospadias, the ideal age for a surgeon to see them is around 3-6 months of age. For children with suspected DSD or small phallus or associated undescended testis, patients should be referred in the first 2-3 weeks of age itself for hormonal and DSD evaluation.

What is the ideal age for surgery for Hypospadias?

We recommend Hypospadias repair in boys between 6months to 15 months of age if they have a good weight and there is no other congenital anomaly. In some preterm babies or babies with a delayed growth, other anomalies – a second window of opportunity is between 3-5 years of age.

What are the Goals of Hypospadias surgery?

Good functional and cosmetic outcome in form of a straight penis, normally located urinary opening at tip of penis, ability to pass urine like a normal child with thick single forceful stream.

Do all Hypospadias need surgery?

Minor hypospadias like glanular hypospadias and coronal hypospadias can be left alone if the meatus is of good caliber, urine flow is in good stream & forwardly directed and there is no chordee. Otherwise, all hypospadias which are distal penile or more proximal in location or have any chordee should be repaired.

What are the tests needed before Hypospadias surgery?

For isolated hypospadias- only simple blood tests and fitness assessment are required before surgery. If there are any associated abnormalities like undescended testis then further detailed testing may be required to rule out DSD. Hormonal tests may be required if the size of the penis is small for age.

How is the Hypospadias surgery done?

Hypospadias requires a corrective surgery called Urethroplasty which involves- correction of penile curvature (Chordee) and creation of new urethra (neourethra) to the tip of penis. Many different techniques for surgery are available and a particular technique is used based on the type of hypospadias/ severity of defect. Some children may require pre-operative hormone injections to improve the size of penis and facilitate and improve surgical results.

Is the surgery done in a single stage or requires multiple stages?

The deciding factor for single or staged repair is the severity of chordee. In cases of mild chordee single stage repair is possible. Complication rates of single stage surgery are less than 10% in good centres such as Hypospadias Foundation and less than 5% may need a second surgery. Staged Hypospadias repair remains an option in very severe hypospadias and those with very severe chordee but such cases constitute less than 10% of all cases.

What is chordee correction and why is it essential?

Chordee is defined as abnormal ventral curvature of the penis. Chordee when left uncorrected or partly corrected can result in painful erection and difficult sexual intercourse. As a first step of any hypospadias surgery, chordee assessment is done after complete degloving. Based on the degree of chordee various methods are followed for chordee correction. The various methods include dorsal tunica albuginea plication, urethral plate division and proximal urethral mobilization, fairy cuts, corporotomies and in severe cases of chordee, a dermal graft for ventral penile lengthening may be required.

What is a post-surgery course and follow-up?

Most of the children are discharged on the same day in the evening after surgery. Some children with severe hypospadias or failed previous surgeries elsewhere may require 1-2 days hospital stay for antibiotic injections and pain relief. Typically, we train the parents to take care of the catheter in a double diaper fashion so that there is no urine bag hanging out. We do not advise any bed rest and children are free to walk around and play the next day of surgery.

At the time of discharge – an antibiotic syrup, analgesic (pain killer) and a medicine to control bladder spasms is commonly prescribed. Dressing is normally removed on day 7 and catheter on day 7-10 depending on the type of repair. After that a follow up visit is needed at 1 month/ 3 months and 1 year after surgery. We also like to see the children at 7-8 years and 12-15 years of age.

What surgeries are done for failed hypospadias?

In expert hands the rate of complications should be less than 10%. The common complications which can occur after hypospadias repair are urethrocutaneous fistula, urethral diverticulum, recurrent chordee and glans dehiscence. There are good techniques available to correct these complications. In children with failed hypospadias after multiple failed surgeries, oral mucosa graft urethroplasty is an option. At hypospadias foundation the results of oral mucosa graft repair are excellent with minimal complications.

Does hypospadias cause infertility?

Isolated hypospadias has not been known to be associated with infertility. Sperm counts of children who were operated on in childhood were shown to be normal. If there is associated undescended testis, then chances of infertility are higher in men with a history of hypospadias. Also, in men with chordee, intercourse may pose technical challenges, hence chordee correction is a must to provide long term normal sexual function.

Final outcome of correction of penile torsion and hypospadias

Results

The Final result was very gratifying with a straight penis without any torsion. The child was passing urine in good stream in straight axis without any discomfort or pain.

About Hypospadias repair and penile torsion

Penile torsion is a condition wherein the penis is rotated or twisted on its axis. The penile torsion is more commonly to the left. Many a time penile torsion may not be detected till a circumcision is planned or foreskin is retracted.

Penile torsion may be associated with hypospadias and/or chordee (penile curvature). With hypospadias, penile torsion is mostly associated with distal penile cases.

Based on the degree of glanular rotation, penile torsion can be classified as mild, moderate, and severe. It is mild if its less than 45 degree, moderate if it’s between 45-90 degree and severe if more than 90 degree.

Penile torsion in majority of cases (>85%) is between 10 to 20 degree. If it is a moderate or severe degree of torsion, urine stream may be deviated to one side.

Surgical intervention is not always required in isolated penile torsion. The indications for surgical correction are cosmetic, functional, or sexual. When penile torsion is associated with hypospadias, it should be corrected along with Hypospadias repair or urethroplasty at the same time.

About Hypospadias Foundation

Hypospadias foundation is a centre which provides personalized and best quality care for children and adults with hypospadias. It is one of the best hospital centres in India and world for surgical treatment for hypospadias in adults and children. Our dedication in the field of hypospadias has helped us achieve excellent outcomes in these patients. We treat children and adults not only from various parts of India but also from more than 25 countries all over the world. Hypospadias foundation is located at MITR hospital in Kharghar, Navi-Mumbai, Maharashtra, India. Every year more than 200 surgeries for hypospadias are performed at MITR hospital and Hypospadias Foundation

Contact us:

For appointment kindly contact us at the contact details given below.

MITR hospital & Hypospadias Foundation, Kharghar, Navi Mumbai, India
MITR Clinic: C1/8 Ground floor, Sector-2, VashiCall

Call for appointments: +91-2227743558/ 27744229/ 39/69 and +919324180553.

Or you can fill up this form- Contact form for Dr Singal

Fill up contact form: https://www.hypospadiasfoundation.com/contact/

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Category Archives: About Hypospadias

Single Stage Hypospadias Repair In A Boy After Multiple Failed Hypospadias Surgeries

Contact Form for Hypospadias Foundation

Contact Form for Hypospadias Foundation

Dr. Singal presented the following lectures and papers in the World Congress:

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