Evolution in Hypospadias treatment

Hypospadias management has undergone big changes in last two decades. The results and outcomes of surgery have improved tremendously making hypospadias management a lesser headache for the doctor and the parents. Two decades back the results for hypospadias surgery were not so predictable and the surgeons and the family all used to be ready for mentally and financially for 2-3 surgeries and that too with suboptimal cosmetic and functional results.

Some of the things which have helped this change are:

• The newer techniques of  single stage urethroplasty (hypospadias surgery) such as onlay flaps,  Snodgrass repair and prepucial tube repairs.
• Newer and finer sutures to do the surgery such as PDS, monocryl and vicryl rapide
• Fine microsurgery instruments for doing surgery on delicate penile tissues
• Uniform use of optical magnification by surgeons while doing surgery
• Day care surgery avoiding long hospitalization and infact the whole focus is on sending the children home the same day in most cases
• Good antibiotics and  pain relief in post surgery period
• Early age at surgery – Surgery is nowadays usually done at 6-9 months of age for a child who is otherwise well
• Trained surgeons and teams dedicating time and energy towards giving a good outcome in children with Hypospadias
• Surgeons with mindset firmly towards doing a single stage repair. Mindset change has been a key catalyst towards single stage surgeries.

For a penile hypospadias whether it is mild, moderate or severe (distal, mid or proximal penile), the success rates for a single stage urethroplasty are close to 95% now; meaning that only 5% of the children require a second surgery for urethral fistula and even lesser for a stenosis. This is very heartening and gives confidence to the family as well as the doctor treating children with hypospadias. For such cases, it has become like any other surgery now, the child comes to the hospital on the morning of surgery, gets the surgery done in 1-2 hours, goes home by evening playful, active and pain free. Only thing the parents need to take care is regular medicines and diaper changes. This is certainly a huge step from 1990’s where these kids were kept admitted in the hospital for a week or ten days while they recovered after surgery.

At home children eat better, feel better, are with family and there are lesser chances of hospital acquired infections with resistant bacteria. Happiness and good food is a key ingredient for a child getting a favorable result and this component is often understated and misunderstood. Keeping the child for a prolonged duration of time in hospital only increases cost of the surgery, amount of medicines used, discomfort faced by family and also risk of hospital acquired infections.

Surgeon training in Pediatric Urology also has a great bearing on the outcomes of hypospadias repairs. With advancing experience, depth of academic and anatomical knowledge, devotion of time to hypospadias is the key to better results seen for some surgeons. It is often said that in Pediatric Urology specialty, to have good results in hypospadias surgery is often the acid test. It may be easier to excel in Laparoscopy or Endourology but still challenging to provide uniformly good results in hypospadias. The repairs and the depth of knowledge and understanding required is challenging and first few cases are unpredictable with respect to outcomes and a lot of young surgeons get disheartened and stop investing themselves into the art and science of hypospadias management. First few failures often bring out the fears and some surgeons find it difficult to continue in this unsure scenario. I still don’t know a single surgeon who never had a complication with hypospadias repairs or has stopped having complications in hypospadias. They do happen even with the most dedicated & expereinced surgeons as medical science is often an imperfect science thus lending the term “I practice medicine” but with growing volumes or experience and most importantly using the catalyst of dedication the results can quickly become very good, predictable and measurable. The complication rates/ second surgery rates become manageable and suddenly it seems enjoyable.

It is very important that a surgeon enjoys his work- it should be like meditation while doing surgery wearing magnifying loupes with all the attention solely on a 2 inch area trying to finish the nature’s unfinished business with human hands. When this happens, that is when the results are acceptable to the surgeon and the parents.

Distal Penile Hypospadias repair surgery by Dr Singal

Severe Scrotal Hypospadias- Single stage repair by Dr A.K.Singal