Redo Hypospadias Archives - Hypospadias Foundation

November 11 2024

Single stage hypospadias repair in a child using residual prepuce after previous failed surgeries

5-year-old boy with distal penile hypospadias, had undergone two surgeries somewhere else and came to Hypospadias Foundationnted with complaints of difficulty in passing urine from the meatus and urine leak from the distal penile region. On clinical examination, there was residual chordee, fistula in the distal penile region and penile torsion to the right.

At our centre, he was planned for cystoscopy, chordee assessment and single or two stage repair based on the cystoscopy findings. On cystoscopy, we found stricture of length 1.5cm in the distal urethra (beyond the site of fistula) and normal proximal urethra.

As a first step, the penis was degloved. Fibrotic bands were released during degloving. Chordee was assessed by artificial erection test and no chordee was noted. The dorsal penile skin (residual prepuce) looked healthy with preserved vascularity. Hence, we planned to go ahead with the urethroplasty in single stage using an onlay flap from this residual prepuce.

15x8mm flap along with the good vascular dartos tissue was raised from the dorsal side. Flap was rotated around the side of the penis and brought to the underside of the penis for urethroplasty. Urethroplasty was done using 6-0 PDS over a 7Fr infant feeding tube. Dartos tissue was fixed on either side to cover the urethroplasty. Glans wings were raised widely and glansplasty done using 6-0 PDS. Excess skin was trimmed on the right lateral side and repositioned to correct the penile torsion and to achieve a better cosmetic result.

Pic 1: Preoperative assessment shows penile torsion to the right and mild residual chordee

Pic 2: Complete degloving done, artificial erection test showed no chordee

Pic 3: Scarring noted in the urethral plate and fistula tract identified

Pic 4: Marking of the prepucial flap and prepucial flap raised preserving the vascularity

Pic 5: Glans wings widely raised and Onlay flap urethroplasty done over 7Fr IFT with 6-0 PDS

Pic 6: Onlay flap urethroplasty done over 7Fr IFT with 6-0 PDS and dartos flap spread fixed on either side

Pic 7: Skin rearranged and sutured in 2 layers using 6-0 PDS and 6-0 vicryl rapide

Pic 8: Post operative cosmetic outcome at 2 months after surgery- passing urine in single straight stream with no leak

Single stage hypospadias repair in a child using onlay flap from residual prepuce after previous failed surgeries

Hypospadias is a birth defect in boys where the urinary opening is on the underside of the penis. One of the popular techniques used for hypospadias repair is a Prepucial Onlay Flap urethroplasty. In this surgery, a well vascularized flap is raised from the dorsal prepuce and used to reconstruct the urethra.

This technique can also be used in failed hypospadias in the presence of residual prepuce and with no or minor chordee. The success rate of onlay flap in a failed hypospadias varies depending on several factors including the severity of the hypospadias, the surgeon’s experience, vascularity of the penile skin etc. During the surgery, flaps must be carefully raised preserving the vascularity otherwise there is risk of flap necrosis and complete dehiscence. Post surgery dressing should not be tight because it can cause compression of the flap and compromise the vascularity. This repair has good outcomes when performed by an experienced hypospadias surgeon.

If your child has undergone prior hypospadias repairs and developed a complication, then do consult an expert hypospadias surgeon for your child. Discuss the best options for your child and take an informed decision from the best in the field of hypospadias.

About Hypospadias Foundation

Hypospadias Foundation is a centre specialized for treatment of children with hypospadias. Our expertise in hypospadias makes us one of the best centres for hypospadias repair in the world. We treat children from more than 25 countries in the world and from all over India. Our dedication in this field has helped us achieve excellent outcomes. Hypospadias foundation is located at MITR Hospital in Kharghar, Navi Mumbai in the state of Maharashtra.

Dr A K Singal is an expert and top hypospadias surgeon in India. He is a gifted surgeon and his expertise in this area has helped us achieve excellent outcomes in primary and failed hypospadias in children as well as adults.

Dr Ashwitha Shenoy is an expert hypospadias surgeon with special interest in hypospadias and pediatric urology. Both Dr Singal and Dr Shenoy work together to give best results for hypospadias surgery in India for both children and adults.

September 09 2023

Flip flap urethroplasty for single stage repair in a case of redo hypospadias

An 11-year boy presented to hypospadias foundation with two failed surgeries in the past done elsewhere and currently passing urine from two places – the tip and from the coronal region. On clinical examination, there was a glans bridge between the meatus and fistula with healthy and mobile skin proximal to the fistula. In view of no residual chordee and healthy distal skin we planned to treat this child by a flip flap urethroplasty.

Fig 1 & 2: Clinical examination showing coronal fistula and glans bridge between meatus and fistula

Fig 3: Artificial erection test shows no residual chordee

Child was taken under anesthesia. As a first step, the bridge between the meatus and fistula was divided. A U- shaped incision was marked on the ventral penile skin at an equal distance from the corona to the proposed neomeatus. Incision was given at the marked site and stay suture was taken at the apex of the incision using 4-0 prolene. Incision was deepened and a flap of skin with thick vascular subcutaneous tissue raised. Glans wings were raised widely on either side. Flap was flipped distally to cover the urethral plate. Bilateral edge to edge anastomosis between the flap and urethral plate was done using 6-0 PDS over an 8Fr catheter. Local tissues closed as a second layer over the urethroplasty using 6-0 PDS. Glansplasty done. Penile skin beside the flap mobilized and skin closed in the midline using 6-0 PDS.

Post Op care: The catheter and dressing were removed on day 7. The child passed urine in a good stream without any complications of hypospadias repair. At 6 months follow up the child is doing very well without any issues.

Fig 4 & 5: U shaped incision marked. Incision deepened and flap raised.

Fig 6 & 7: Glans wings mobilized. Flap sutured to the urethral plate on either side and urethroplasty done.

Fig 8: Flip flap urethroplasty complete

Fig 9: Urine stream following catheter removal.

About Flip flap urethroplasty

The main aim of Hypospadias repair is to achieve a forward straight urine stream and normal or near normal looking penile appearance after hypospadias surgery. The important factors to be considered during any hypospadias repair are glans groove, urethral plate and chordee. Each patient with hypospadias is unique and these factors help us to decide the type of repair possible in them.

The case mentioned above had already undergone two hypospadias surgeries in the past but the surgeries were unsuccessful with formation of urethral fistula. However, he had a no chordee, wide urethral plate with healthy and mobile skin around the meatus. Taking into consideration these findings and the need for a short segment repair we decided to go ahead with flip flap urethroplasty for this boy. Flip flap urethroplasty is an excellent option of repair in failed cases with healthy penile skin with no scarring. This repair may be used in failed distal hypospadias repair in the absence of chordee with adequate meatal opening and flat urethral plate which cannot be tubularized.

At our centre the flip flap repair for failed cases has more than 90% success rate. Expertise in this area and proper case selection has helped us achieve excellence in treating even the most complex hypospadias.

About Hypospadias Foundation

Hypospadias Foundation is located at MITR hospital in Kharghar, Navi Mumbai in the state of Maharashtra. Every year we get children and adults from all around the country and the world in search of a cure for hypospadias. We have recently completed 14 years of hypospadias foundation and have successfully treated thousands of children and adults with hypospadias over the last 14 years. Our dedication, determination, and perseverance in the field of hypospadias has helped us achieve excellent outcomes.

Dr A K Singal is a top and expert surgeon who has dedicated his life in treating children and adults with hypospadias. His expertise in this area has helped us achieve excellent outcomes in adults and children with hypospadias.

Dr Ashwitha Shenoy is an expert pediatric surgeon with special interest in pediatric urology and hypospadias. Both Dr Singal and Dr Shenoy work together to give best results for hypospadias surgery in India for both children and adults.

March 03 2020

Failed Hypospadias Surgery- Second opinion from a Hypospadias Specialist surgeon may help

Hypospadias remains one of the most common urological anomalies in children. With almost 1/150 boys across the world born with hypospadias every year, there is a large number of children with hypospadias who do not reach the right hypospadias doctor. Failed hypospadias surgery can compound these challenges, highlighting the importance of seeking specialized care. Hypospadias is a complex anomaly, and there are many variations possible in anatomy which dictate the type of surgical repair being done and results thereof.

Results and complications of hypospadias surgery depend on the experience of the hypospadias surgeon and his interest in managing the condition. While some hypospadias surgeries fail due to failure on the part of the surgeon to select the proper technique of repair, others fail due to unknown reasons and it is difficult to go back and check whatever the reason may be. Unfortunately the time only moves one way and that is forward.

The common type of failures or complications seen in hypospadias surgery are:

Urethral fistula- leakage of urine from somewhere other than main hole- 2-3 streams may be seen. Fistula formation is the most common complication of hypospadias surgery.
Stricture or stenosis: new passage may become tight leading to narrow stream, painful urination and straining to pass urine. This can be at the tip- meatal stenosis or somewhere down in the new passage.
Curvature: Sometimes surgeon doesn’t correct the chordee fully because of which there is residual chordee. Remember if the chordee is not corrected fully in the first surgery, there is always a chance of failure of surgeries and future complications. Hence, chordee correction is the most important step in the hypospadias surgery.
Diverticulum: here the new urethra balloons up leading to visible swelling in the penis while passing urine. This can lead to local and urine infections as well difficulty in passing urine.
Dehiscence: Sometimes the repair gives way completely- this can be at the level of glans (glans dehiscence) or partial or complete dehiscence
Penile torsion: If the penis is rotated around its axis, it is called penile torsion. Sometimes the penile torsion is present before the surgery or it can happen post-surgery also due to complication of the hypospadias surgery itself.
Poor cosmetic result: If there is kin level sinus formation, uneven tags or even penile skin shortening, this can lead to poor cosmetic outlook.

How second opinion can help for a child or adult with failed hypospadias

Hypospadias is one clinical condition where we do not need any complicated tests or examination to determine if the child had a success of the hypospadias surgery or not. If the child is passing urine from the tip of penis, in a single, straight, thick stream comfortably and the erections are straight- they know that the surgery has been successful.

Often the primary surgeon may be not able to manage the complication, may not be an expert in managing failed hypospadias, or may not be able to think through the complication roadmap due to a mental roadblock. In such situations, an expert neutral second opinion from an experienced hypospadias surgeon may help significantly. A new line of treatment or a fresh perspective may help in finding the right solution. At Hypospadias Foundation, we often see cases where the first surgeon has tried 3-4 surgeries, sometimes even 6-7, and they have not worked; clearly, a new approach should have been taken to give a good result. If you’re dealing with the aftermath of failed hypospadias surgery, trust in our expertise for comprehensive evaluation and personalized solutions.

How to take a second opinion for hypospadias

You can just fill-up this form (Contact form for Hypospadias) or send an email to hypospadiasfoundationindia@gmail.com or communicate via whatsapp with Dr Rajkumar – +919821261448. It is best to send pictures of penis, a short video of child passing urine and pictures of previous surgery records. A short summary in a word document also helps us in understanding the issue. We typically get back with an opinion within one week.

Payment for second opinion

Most of the times if it is a basic opinion & short straightforward case, Dr Singal discusses with Dr Rajkumar and then Dr Rajkumar sends an outline of suggested approach via email. There are no charges for a basic second opinion. Dr Rajkumar has been working and managing all remote consults at Hypospadias Foundation for more than 10 years and has managed more than 2000 cases with Dr Singal.

At other times if the parents wish to speak to Dr Singal or the case requires and extensive review which can’t be done in a short while, then it is time commitment from Dr Singal. Such consultations are chargeable and done on phone or skype. Typical charges vary from 1500 INR to 100 USD.

Can second opinion be given without in person examination?

With the availability of good pictures, videos, medical records and reliable history- a very reliable second opinion can be given for hypospadias. Very rarely, the case is too difficult or needs a physical examination, in such cases we let the family know about this in advance.

Be rest assured that a good outcome after treatment at Hypospadias Foundation in India is a common and mutual goal for us and the family. We get children from all over the world who travel far and wide to India for finding a cure and best results for their child’s failed hypospadias. And we give our best care and treatment to all such families.

Dr. Singal during Hypospadias Surgery

Contact Form for Hypospadias Foundation

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

January 01 2020

A small complication in hypospadias surgery does not mean the end of the road: Surgeon and Family must work together

Hypospadias Foundation starts Clinic for Hypospadias Treatment & Surgery in Bahrain

Let me begin by saying: Hypospadias Repair surgery is not an easy surgery.

It takes a surgeon years to perfect the art and craft of hypospadias surgery. Every single slice of knife, every single snip of scissors, every single stitch holds the key to a successful hypospadias repair. Inspite of all this, sometimes the results of hypospadias surgery may be suboptimal. The reasons for this are many. Besides an undertrained surgeon or poor equipment or expertise, sometimes the healing after hypospadias surgery is unpredictable. Even after hypospadias surgery, the penis has erections every night, putting the repair at little bit of stress. There may be minor infection, or the child may be nutritionally deficient in micronutrients leading to poor healing. Even if these factors are controlled, individual healing is still very variable phenomenon, leading to a small rate of complications even in expert hands. In best hypospadias centres, hypospadias complications dip to less than 5% for distal hypospadias and less than 15% for severe hypospadias.

Any complication which happens can be disheartening for the family, the child as well as for the hypospadias surgeon. Surgeons particularly get emotionally disturbed and keep thinking about it even when they go back home and more so the surgeons who are sensitive. We as surgeons forget out 95% successes and keep carrying the burden of our complications back to our homes and our families, even the minor things haunt us. Though we may keep a strong face on the exterior, much required, inside we suffer every time something doesn’t go well. Hence, we keep striving for better and better results.

Dr A.K.Singal, Pediatric Urologist India

Well coming back to the point- One of the most common complications of hypospadias surgery is Urethral Fistula formation. Having a complication such as fistula is not the end of the road. If the family has faith and the surgeon is experienced, urethral fistula can be managed easily with a minor second surgery in most of the cases.

I wish to share one story sent by the parents on an email to us and without any changes. The family came to us from Pune to Navi Mumbai for hypospadias treatment. Here we go:

It was indeed the happiest day of our lives when we welcomed our little bundle of joy; but soon after our son was born, the paediatrician informed us the baby is having a condition called Hypospadias with chordee albeit the degree of both the conditions was really minor, yet requiring surgery. The term Hypospadias was unheard of until then by us as well as seniors in the family. It was so devastating for us to know that the little one is already scheduled for the surgery – especially on such delicate place – before even he is a month old. Although the surgery was never life threatening and was elective in nature, as parents we were extremely nervous and anxious. Like every anxious parent, we too googled about the condition – which helped us understand better about hypospadias – before taking the next step of seeing the surgeon. Here in Pune, we did meet at least 2-3 paediatric surgeons (not the urologists or who specialise in hypospadias surgery). A senior doctor suggested 2 surgeries even for this minor hypospadias. Later we met 2-3 more doctors who suggested various methods be it keeping baby hospitalised for 7 to 10 days with medicines administered through IV lines or keeping the baby open after catheterization plus keeping his legs tied to each other in order to avoid dislodgement of catheter when he moves his legs; not to mention we were extremely petrified after meeting all these doctors as they were not at all empathetic not cordial. Not unexpectedly we were not convinced with any of the doctors as through google we already had understood that the condition can be treated as a day care surgery and babies are managed on oral medicines and in double diapers. Here, no doctor was talking about diaper and taking the baby home next day if not the same day. With due to respect to these doctors, we didn’t want to go ahead with the doctor with whom we were not comfortable with whatever little knowledge we have had gathered on this subject. The question of finding the right doctor was still there. Again, while googling we could get to know that there could be doctors who specialise as paediatric urologists and have vast experience of treating the babies / kids with hypospadias. Thanks to google and age of internet we found Dr. A.K. Singal.

The day we met Dr. Singal:

By the time we met Dr. Singal, our son was already 5 months old. After meeting Dr. Singal we realised why things didn’t move ahead with the previous doctors. Meeting Dr. Singal was so up to the mark as he explained the condition in detail, what he will be doing in the operation theatre and how the baby will be managed post-surgery. He was not only empathetic but also cordial and could understand what exactly the parents must be going through when their little ones must go through the surgery at very young age. His attitude was very positive. We had met the doctor we were looking for. Needless to say, we were so convinced and decided to go ahead with the surgery by Dr. AK Singal. He confirmed that both the defects would be covered in one surgery and the chances of any complications could be considered up to 2-3%. The age he suggested for the surgery was between 6 to 9 months. We took our own time to decide on the date of surgery and scheduled it when he was 14 months old. In the meanwhile, we met Dr. Singal twice with the doubts that we had. Each time he was very cordial in explaining the doubts in detail.

On the day of Surgery:

It was finally the day of the surgery. Nevertheless, we knew that the surgery is going to be for baby’s own good, yet our hearts were in the mouth. The doctor, as well the staff are so good that they would cater to every alarm by an extra-anxious and sensitive parent like me. The surgery went well, and the baby was brought back to the room. He was sleeping most of the day but when he opened his eyes I missed my heartbeat in the anticipation that he, now, would feel pain and the soreness; but to our surprise, he did not have any post-surgical pain on that day and any following day thereafter till the wound was healing. He was at his playful best by the next morning of surgery. He was kept in double diapers i.e. a hole was made in the inner diaper through which catheter was brought out and left to drain in the outer diaper. This method provides a cushion to the operated site, avoids catheter getting pulled accidently and makes it easy for parents to carry the child. Doctor suggested us to go home the next day, but we decided to continue for one more day for the betterment of the child. The nurses were so attentive and very cordial. After removal of the dressing and catheter, unfortunately our son caught the infection at the operated site which resulted in an extremely tiny fistula, which could not be spotted unless seen with the extreme care. This fistula was so tiny that the urine would come out from it in a drop or two. Later, as he was growing the urine output from the fistula grew to multiple drops.

Next appointments with the doctor:

Despite our son developed the fistula, our faith in the doctor never faded away as we were sure that doctor must have done his job with 100% care, and it was our and our baby’s fate to have the complication. The doctor never rushed and pushed us for the second surgery. He was hopeful that this tiny fistula can be healed on its own over the course of time; but the misfortune may have it, the fistula never healed, and worsened with the age by the end of year 2018. We had no choice but to put him through yet another surgery. This time as well the same protocols were followed and now our son is doing good after relatively minor second surgery.

Notes for the parents:

Please do your research when your little one requires any kind of surgery.
Have your questions ready so that you don’t miss any of them while you see the doctor
Trust your vibes. Don’t go ahead with the doctor unless you’re 100% convinced.
Get all your doubts cleared before you schedule your little one for the surgery
Take a note of your baby’s food habits and arrange for them well in advance, especially if you are an intercity / interstate / international patient. Carry sufficient (or maybe surplus) supplies during this crucial time as the baby / child can be cranky due to change in schedule and nonetheless due to procedure.
Carry his / her favourite toys, as that can sooth them.
Engage them with cartoon videos
Most importantly, however low and stressed you feel, never show baby /child your emotions and keep the spirit high. This is a tough time which too shall pass, just hang in there.
Follow medicine schedule very promptly. Be on top of the pain. Be very punctual when to comes to medicine schedule.
Be vigilant but don’t panic, call the hospital if you are not sure what to do?

Hope this story helped the families out there in some way. The lessons from the story can help both the surgeon and the family in having faith in the worst of times.

Take care and god bless.

Dr Singal

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