Redo Hypospadias Archives - Page 2 of 2

January 01 2019

From Assam to Navi Mumbai – A child with Failed Hypospadias surgery treated by Buccal mucosa graft urethroplasty at Hypospadias Foundation

Hypospadias Foundation starts Clinic for Hypospadias Treatment & Surgery in Bahrain

Hypospadias repair surgery all over the world is done by surgeons from various fields such as Pediatric Urologists, Pediatric Surgeons, Urologists and Plastic surgeons. Considering that the number of children who suffer from Hypospadias is very high (almost 1 lakh in India every year and 3 lakhs all over the world), and that there are very less number of pediatric urologists in India (less than 10) it is obvious that majority of hypospadias would not be able to reach a pediatric urologist for best hypospadias treatment. That being said, results of the hypospadias surgery depend on the experience and interest of the surgeon in treating children with hypospadias more than the degree. Once a surgeon is doing more than 50-60 hypospadias repairs every year, the results of hypospadias surgery improve significantly. The accepted rate of complications in hypospadias correction is less than 25% in proximal severe hypospadias and less than 10% in more common distal or midpenile hypospadias. The children who have a failed hypospadias surgery may need a second surgery and in some cases even more surgeries. These failed hypospadias surgeries must be done by a hypospadias specialist or an expert hypospadias surgeon for best results.

Master A.R was born in Dibrugarh (Assam) and was noted to have a distal penile hypospadias. He underwent hypospadias repair surgery at Dibrugarh, Assam by a Pediatric surgeon at 2 years of age. After hypospadias surgery, he was kept in hospital for 10 days but upon removal of dressing he was noted to have complete breakdown of the hypospadias repair. His urinary opening had regressed back to the same location. Parents were very disturbed by the outcome and the treating doctor told them a second surgery will be needed in 6 months. Parents consulted surgeons in Calcutta (Kolkata) for second opinion for hypospadias but were not happy with their proposed approach. They came to know about Dr A.K.Singal, Hypospadias specialist surgeon doctor at Hypospadias Foundation in Navi Mumbai and contacted us. Finally, in November 2014, the family traveled from Assam in search for second surgery and complete treatment for Failed Hypospadias of their son.

On examination, Master A.R. had a complete dehiscence (breakdown) of the previous hypospadias repair and the urinary opening was still in distal penile location. The glans was open and there was excess skin on one side of penis due to previous surgery. The urethral plate was practically non-existent probably due to scarring from first hypospadias surgery. Parents were explained the various options for the second stage repair for hypospadias. Since there was some extra skin on one side we planned to use parts of it for final repair or use the buccal (oral) mucosa graft (lining of mouth either from cheek or lip).

During surgery, we observed that the skin on the side of the penis had a poor blood supply and was unsuitable to be used for onlay flap for urethroplasty. The second option was to use a buccal mucosa graft either in two stages or in one stage as an inlay graft. We decided to place the graft first as an inlay graft and then decide whether we can do the repair in single stage or do it as a staged urethroplasty. We harvested a 3 cm x 1 cm graft from the lower lip and defatted it nicely. We opened the urethra till we found a normal caliber urethra with thick walls. Then a midline deep incision was given in the urethral plate and graft was sutured in place with very fine absorbable sutures (6-0 PDS). This expanded the urethral plate especially in the head of penis (glans). Single stage inlay buccal (oral) mucosa graft urethroplasty was finished over 8 Fr catheter. Dressing was removed on day 5 and catheter was removed on day 10. A.R. passed urine well after catheter removal with excellent healing of the tissues. Though, he developed minor meatal stenosis (tight opening), this did not need any further surgery. Now after 6 months of surgery, he is doing well and happy passing urine from the tip of penis.

About Buccal (oral) mucosa graft urethroplasty:

Buccal mucosa is the lining of the inside of mouth (Cheeks, lips) and is a very suitable tissue to be used for certain specific situations in failed hypospadias surgery. Buccal mucosa urethroplasty is done for those cases where due to previous failed surgeries there is shortage of skin on the underneath of penis and there is no residual prepuce (foreskin). In primary hypospadias (where no surgeries have been done), there is no role or need for using buccal mucosa.

Parents often get alarmed when they are told that we will be using something from mouth for surgery on penis. But since this is a thin layer and the buccal mucosa has excellent regeneration capacity, once we remove a superficial thin layer, the defect doesn’t even need suturing in most cases. The new lining re-appears in 3-4 days’ time and there is no major long-term problem in most cases. Buccal mucosa is hairless and is used to staying wet, hence it is ideal for urethral reconstruction. Like any other graft, once it is taken from mouth and placed on penis – it has to take new blood supply locally. Hence whenever there is a big graft being taken, we wait for 5-6 months before doing the next surgery. In the present case, since the graft was small- we elected to a do the single stage buccal graft urethroplasty with a good result.

About the author:

Dr A.K.Singal is a renowned Pediatric Urosurgeon and one of the best hypospadias surgeons in world and India. Every year, he treats more than 150 kids and adults with primary and failed hypospadias at Hypospadias foundation in Navi Mumbai, India and at Ibn Al Nafees Hospital in Bahrain. Some of these failed hypospadias patients had given up hope for a good result before their referral to Hypospadias Foundation for successful treatment. With the team work and years of experience in treating patients with complex, severe and failed hypospadias, at Hypospadias Foundation we are able to give them cure and their normal life back.

To contact Dr Singal, Submit your enquiry here: http://www.hypospadiasfoundation.com/contact-form-for-patients/

Watch Surgery Video for Failed Hypospadias by Dr Singal

January 01 2019

A child with multiple Failed Hypospadias surgeries finds cure at Hypospadias Foundation with Staged Buccal (oral) mucosa graft urethroplasty

Hypospadias Foundation starts Clinic for Hypospadias Treatment & Surgery in Bahrain

Hypospadias is very common congenital birth defect of penis. Most of these children require surgery in childhood. The accepted rate of complications after hypospadias repair in less than 20% in sever and under 10% in milder distal or midpenile hypospadias. When the first surgery for hypospadias fails, the children may need a second redo surgery and in some cases third or more surgeries. Such cases are best managed and treated by expert hypospadias surgeons or hypospadias specialist doctors.

Master AKM was born in Mumbai India. He was noted to have severe proximal penile hypospadias. He underwent one hypospadias repair at the age of 5 years and another one at 8 years of age. He developed pain in passing urine and used to really cry at time of passing urine. The treating surgeon at a top mumbai hospital, tried to open the urethra by taking under anesthesia and dilating 3-4 times but the symptoms of pain while passing urine returned again and again.

Finally, the parents came to Hypospadias Foundation in Navi Mumbai and contacted us. The child was attended to by Dr A.K.Singal, Pediatric urologist & hypospadias surgeon. On examination, Master AKM had pus at the new opening of penis which was little under the head of penis even after previous multiple surgeries. The penis skin also looked unhealthy and hard at places. The child was admitted and given antibiotics by injections. Parents were explained about the serious condition and that cystoscopy will be needed to check the reason for child’s difficulty in passing urine.

During cystoscopy, it was realized that the new urethra made during surgery had all become very tight (Stricture). The urethra beyond penile region was also unhealthy till bulbar region near prostate gland. A condition called BXO (Balanitis Xerotica Obliterans) was suspected as the cause of the stricture. Dr Singal discussed with family for the need to open the entire urethra till prostate gland and then put skin from inside the mouth on underside of penis (Buccal mucosa) and then come and do the second stage surgery after 6 months. The parents agreed for the plan for staged buccal (oral) mucosa graft urethroplasty.

The urethra was opened on the underside of penis till bulbar region. Long buccal mucosa graft was harvested from right inner cheek. Since a long graft was needed, another buccal graft was taken from the lower lip (labial oral graft). For the proximal urethra- cheek buccal graft was placed as dorsal inlay graft and urethra was closed till penoscrotal region. From Penoscrotal region till glans- buccal graft from lip and cheek was placed, fixed and left open. A tie-over dressing was done to fix the graft and help in graft uptake.

After 6 months, the graft looked pink, healthy and soft. Second stage urethroplasty was finished over 8 Fr catheter as the graft and surrounding tissues looked supple now. Dressing was removed on day 5 and catheter was removed on day 10. AKM passed urine well after catheter removal with excellent healing of the tissues. We did a uroflowmetry to check flow of urine, it showed an excellent flow rate of 25ml/ sec. AKM remains well after two years of surgery and is growing up to be a smart young man. He and his family have put up all bad memories behind them and are keen to help other families who have kids suffering from hypospadias.

About buccal mucosa graft urethroplasty:

Buccal (oral) mucosa is inner lining of mouth (Cheeks, lips) and is a very good layer to be used for redo surgery in failed hypospadias. Buccal mucosa urethroplasty (also called oral mucosa graft) is recommended when there is shortage of skin on the underneath of penis and there is no residual prepuce (foreskin). Hence, buccal grafts have no role in primary or first surgeries for hypospadias.

Parents often get very worried and alarmed when we as hypospadias surgeons tell them that we will take the skin form the mouth to make urine passage in penis. The reasons are:

Buccal (oral) mucosa has excellent healing properties
Buccal mucosa is soft elastic and is used to wetness
It never grows hair when put inside penis.
Buccal mucosa does not get BXO
Graft sites heal very fast and child can eat normally in a day or two
There is very small chance of any cosmetic deformity as the skin is taken from inside, there is no cut outside the mouth.
Like any other graft, once taken from mouth and placed on penis – it takes new blood supply. Hence, it is better to wait for 6 months before doing the next surgery, in cases where a large graft has been taken.

About the author:

Dr A.K.Singal is a renowned Pediatric Urosurgeon and one of the best hypospadias surgeons in India. At hypospadias Foundation in India and Bahrain, he takes care of more than 150 kids and adults with primary and failed hypospadias. Hypospadias foundation is located at MITR Hospital in Kharghar, Navi Mumbai, India and at Ibn Al Nafees Hospital, Manama, Kingdom of Bahrain.

With the team work, expertise, dedication, a bit of luck and years of experience in treating patients with complex, severe and failed hypospadias, at Hypospadias Foundation we are able to give them cure and their normal life back.

To contact Dr Singal, Submit your enquiry here: http://www.hypospadiasfoundation.com/contact-form-for-patients/

July 07 2015

Single stage hypospadias repair surgery video for a child with failed hypospadias: Nagpur to Vellore to Navi Mumbai, India

Like every other surgery, hypospadias correction surgery has its own risks, complications and failures. Inspite of the best intentions and efforts of the parents and the treating hypospadias surgeon, still the results may be sub-optimal after the first surgery. Though at the end of hypospadias surgery in OT it may seem that the surgery has gone very well, sometimes there may be minor complications which necessitate a second surgery for hypospadias in some children. The rate of second surgery for a complication or failure of first hypospadias surgery decrease with the expertise and experience of the hypospadias surgeon but it is never zero and that is an important thing for the parents and families to understand.

When the first surgery for hypospadias fails, parents get very disturbed and start looking for more information on why it happened and the solutions and second opinion for hypospadias to help fix the problem. Most of the times, the primary surgeon may be the best person to solve the problem but sometimes the complication may be severe and in such cases the patient should be referred to a centre of excellence in hypospadias surgery.

While minor problems like fistula or cosmetic issues can be treated easily with as second minor surgery- major complications of hypospadias surgery such as urethral breakdown, dehiscence, urethral diverticulum or stricture may require more complicated or even a staged repair with grafts. Hence, the dictum- that first surgery for hypospadias is the best surgery- further surgery if the first one fails is always more difficult and challenging.

At Hypospadias Foundation, we regularly receive kids and adults from all over India and other countries who have had a failed hypospadias surgery elsewhere. Families request for a second opinion for the hypospadias treatment and we advise them comprehensively. Some of these cases really benefit from the specialist care offered by a dedicated hypospadias team.

Case Story

Master A.G., a 3 years old boy, resident of Nagpur, underwent a surgery for a proximal penile hypospadias surgery at a hospital in Vellore. Unfortunately, the healing was not optimal and the whole repair had a breakdown. After 6 months of previous surgery, the family wrote to us and visited us at our centre in Kharghar, Navi Mumbai. On examination, the child has proximal penile meatus with mild chordee. There was a remnant of foreskin (prepuce) on the underside of penis. There was no foreskin left on the topside of penis. We explained to the parents that this may require a two stage repair but we will try out best to make a flap from the residual foreskin and do the surgery in one stage.

Finally after pre-surgery tests and fitness assessments, we took the child for redo-hypospadias surgery. We could make a nice onlay flap out of the foreskin remnant by carefully dissecting the blood supply and preserving the supply to this flap skin. The flap was used to make the new urethra in one stage as it can be seen in the video below. The surgery took about 3 hours and the child was allowed feeds four hours after surgery. The dressing was removed after 7 days and catheter after 10 days. The hypospadias site healed very well and the child was examined again after 1 month. He was passing urine well in a single stream from the tip of penis. Now, 6 months after hypospadias repair, A.G. continues to do well and his parents are very happy and we are also overjoyed to achieve a good result in this challenging failed hypospadias case. The detailed hypospadias surgery video can be watched by clicking below. Besides the story mentioned here, the video below shows another child story from Raipur, Chattisgarh where the first surgery resulted in a penile torsion and a large fistula. The child underwent a successful single stage surgery at Hypospadias Foundation:

Watch Video of Failed Hypospadias surgery by Dr A.K.Singal

If you or your loved one has hypospadias and wish to seek an opinion, please write to us at hypospadiasfoundationindia@gmail.com or contact Dr Rajkumar- Coordinator at +91-9821261448 between 10 am-5pm India Time.

You can also fill up this contact form: Contact Hypospadias Foundation

or come to MITR Hospital in person after taking an appointment by sending an email at frontdesk@mitrhospital.com or calling up at +91-22-27743558/ 4229 or +91-9324180553

Watch Video of proximal penile hypospadias correction by Dr A.K.Singal

Watch Video of scrotal hypospadias repair by Dr A.K.Singal

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

April 04 2015

Successful result in a failed hypospadias repair: Boy from Gandhinagar (Gujarat) visits Hypospadias Foundation for a follow-up 5 years after surgery

Hypospadias remains the most common urological abnormality affecting more than 1 lakh kids in India alone (based on incidence of 1/150 in newborn boys). Leaving aside very minor hypospadias without chordee- almost 70-80% of these require hypospadias treatment in form of repair surgery in early childhood.

For a child with Hypospadias, the first surgery is always the best surgery but still there can be complications and failure even in expert hands though complications are much less if operated by a surgeon or a centre where there is a focused practice in treating children with hypospadias. Literature and experts suggest that if a hypospadias surgeon is doing more than 50 hypospadias repairs in a year, then his results will be better and more predictable as compared to a general pediatric surgeon or a urologist who does only 10-20 hypospadias repairs in a year. Once a hypospadias surgery fails, then the next surgeries become more difficult and result more unpredictable. The failure rate of hypospadias surgeries vary from 5% to 50% depending on the type and severity of hypospadias in general centres and less than 10% in centres where hypospadias surgeries are done by expert hypospadias surgeons on a day to day basis.

Case details

Master A.P. was born with a distal penile hypospadias and underwent first surgery in Ahmedabad at the age of 6 years. Unfortunately, the surgery failed and he started passing urine from the same place on the underside of penis- a fistula. The new urinary passage through the head of the penis got tight and closed off. The surgeon tried to open it many times by catheter insertion but it failed. Coupled with failed hypospadias, the child also had an unsatisfactory cosmetic appearance in form of bunching of skin on underside of penis. With this situation they contacted Dr A.K.Singal, Pediatric urologist and expert Hypospadias surgeon at Hypospadias foundation in Kharghar, Navi Mumbai when the boy was ten years of age. After examining and confirming that the whole urinary pipe will have to be remade from distal penile region to the tip of penis (glans), Dr Singal advised a Onlay island flap repair for which the flap would be raised from the nearby bunched up skin. This repair is technically challenging because of previous failed hypospadias surgery but this was the only chance for the boy to have a single stage repair. The surgery for failed hypospadias was finished in 2 hours and A.P. was ready for discharge the next day but since they had travelled all the way from Gujarat, they decided to stay for 7-8 days in Navi Mumbai. The catheter was removed on day7 and he passed urine well from the tip. For the first one month after surgery, there were some chances of new opening getting tight, hence we taught the boy to insert a small catheter just 1cm into the new opening with an antibiotic ointment. The penis healed well in next 3 months and he has remained free of all symptoms now for last 5 years. At 15 years of age and after his 10^th standard exams, A.P visited us and had a big smile on his face. He is looking forward to higher education and he shared with us his dreams and further education goals. We plan to see him again one last time at 18 years of age. His penis growth and his functional & cosmetic outcome has been excellent so far.

Dr A.K.Singal with the patient

Letter of thanks from the father:

Dear Dr Singal,

My son A.P was operated first at Ahmedabad. The hypospadias problem was not solved and it actually worsened and we were very tense my son’s future life. While searching through internet I came to know about you and your colleague doctors.

From your past surgeries and mastery about Hypospadia surgeries we decided and contacted you before surgery. At Mitr hospital, from the first meeting with you, we were confident about our son’s second Hypospadias surgery and we decided to do it only with you.

At Mitr Hospital, we experienced very good pre and after surgery treatment from Doctors and staff also, very good and polite staff. At Gujarat we don’t have such experienced and professional hospital staff. I think this is also very important besides doctors. I feel that if the doctors are not confident they must not try and go ahead for these type of surgeries because once it is fails, the situation of patient and his family is unbearable. It creates psychological problems also and these can be very stressful to handle. Thanks to your team, my son is doing well now.

Regards

M.P., Gandhinagar, Gujarat.

About Failed Hypospadias repair:

When the hypospadias surgery fails, it is a moment of distress and lot of anguish for the parents. Even the doctors feel terrible because they know that even a hypospadias surgery which has been done well doesn’t mean that everything will heal also well. There are many variable factors which affect healing and hence, complications of hypospadias surgery happen sometimes even in best of hypospadias surgeon’s hands. The only difference being that when an expert hypospadias surgeon does the surgery, the chances of complications decreases drastically. And even if the complications happen, they can be managed well without any panic or long lasting impact.

The complications which may need second surgery are: urethral fistula, tight urethra (stenosis or urethral stricture), residual curvature (chordee), dehiscence (complete breakdown or partial breakdown), diverticulum, penile torsion or an unsatisfactory cosmetic outcome. Once it is ascertained that a second surgery is indeed needed for hypospadias, it is important to wait for 5-6 months before planning the next surgery.

About Dr A.K.Singal

Dr A.K.Singal is a well known Pediatric Urologist and one of the best hypospadias surgeons in India. Every year under his care in Mumbai, Thane and Navi Mumbai, more than 150 children undergo hypospadias treatment. More than 50 of these are children who have failed hypospadias surgery done elsewhere. With his deep understanding and experience, Dr Singal and his team are able to offer care and cure to these children. He can be contacted at hypospadiasfoundationindia@gmail.com or you can call his Assistant Doctor – Dr Rajkumar at 98212161448 if you wish to take a second opinion for a failed hypospadias surgery. Else you can fill up this contact form:

Contact Dr A.K.Singal

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Category Archives: Redo Hypospadias