Failed/ Redo Hypospadias Surgery
First hypospadias surgery in an expert hypospadias surgeon’s hand is the best option for long term outcomes. Hypospadias surgery has a high failure rate in most of the centres around the world unless there is an expert surgeon team with years of experience and interest/ dedication to hypospadias. Typical failure rates go up to 25-30% in most of the centres. However, such surgeons who are dedicated to hypospadias and are doing hundreds of hypospadias every year are few in India and the world. Most of the hypospadias surgeries in India and world are done by pediatric surgeons, plastic surgeons or urologists whose main work is other kind of surgeries.
At hypospadias foundation, every year we treat almost 250 children and adults with hypospadias and of these almost 50% are children or adults who couldn’t get good results after surgery at other centres. Our success rates of over 95% even in those cases where multiple surgeries have been done elsewhere is possible due to diligence and critical decision-making work which we do to have good outcomes.
Most common complications of hypospadias surgery needing further surgeries:
1.Urethral Fistula:
a. What is urethral fistula: Fistula formation is one of the most common complications that can occur after hypospadias surgery. In the case of urethrocutaneous fistula (UCF), the abnormal connection is between the urethra (the tube that carries urine from the bladder out of the body) and the skin. Clinically, parents come with the complaint that the child is passing urine from multiple places in the penis. The reported incidence of UCF after hypospadias repair varies widely, ranging from 5% in specialist centres to almost 40% in general centres.
b. Treatment of urethral fistula after hypospadias surgery: Treatment for a urethral fistula will depend on the size and location of the fistula. Small fistulas may heal on their own within 3 months after surgery. Beyond 3 months they rarely heal on their own and surgical closure of the fistula will be required. If the urethra beyond the fistula site is of good calibre, then fistula closure with a VY advancement flap will work well. If the urethra beyond the fistula site is narrow, then along with fistula closure the entire distal urethra has to reconstructed either in single or two stages.
2. Meatal Stenosis:
a. What is meatal stenosis after hypospadias surgery: Meatal stenosis can occur after hypospadias surgery especially in distal hypospadias repairs. It happens when the opening of the urethra (the tube that carries urine out of the body) at the tip of the penis becomes narrow. In meatal stenosis, the child may have difficulty in emptying the urine along with a weak stream, may take longer time than usual to pass the urine, have pain during urination or upward deflection of the urine stream.
b.Treatment of meatal stenosis: The good news is that meatal stenosis is usually treatable with a minor surgical procedure called meatotomy or a meatoplasty. The meatus is widened by giving a small incision and sutures are placed on either side to prevent it from closing again.
3. Urethral stricture
a. What is urethral stricture after hypospadias surgery: Urethral stricture is an uncommon complication that can occur after hypospadias repair surgery in children. It happens when scar tissue forms in the urethra, narrowing the passage and making it difficult to urinate. Studies suggest it can affect anywhere from 4% to 10% of patients who undergo hypospadias surgery. The child with urethral stricture may have difficulty urinating or a weak urine stream, frequent urination, straining to urinate, dribbling urine, pain or discomfort during urination (dysuria) or even incomplete bladder emptying (urinary retention) in severe cases.
b. Treatment of urethral stricture after hypospadias surgery: A doctor will typically diagnose urethral stricture based on symptoms, a physical exam, and imaging studies like a retrograde urethrogram (RGU-an X-ray of the urethra with contrast dye). If RGU shows urethral stricture then a diagnostic cystoscopy is done to confirm the same and define the exact site of involvement. Once confirmed, the urethral stricture can be managed only with surgery. Unlike other urethral strictures, a urethral stricture which occurs post hypospadias repair cannot be treated by endoscopic procedure or repeated urethral dilatations. For short segment stricture, inlay urethral oral mucosal grafts can work well but for longer strictures, entire urinary passage which was created in the past has to be removed and reconstruction done in two stages. Most of the times oral mucosa graft is used for urethral reconstruction.
4. Residual chordee after hypospadias surgery:
a. What is residual chordee after hypospadias surgery: Residual chordee refers to a situation where the penis remains curved downward even after hypospadias repair surgery. While the goal of surgery is to correct the curvature (chordee) entirely, sometimes some degree of curvature may persist especially if the surgical technique was not properly chosen or there was scarring post-surgery. This can cause difficulty with sexual intercourse and psychological distress.
b. Treatment of residual chordee treated after hypospadias surgery: The good news is that residual chordee can often be treated with additional surgery. The specific approach depends on the severity of the curvature and other factors. Here are some possibilities:
I. Surgery to release scar tissue: This is often the first step in redo/ failed hypospadias with residual chordee. This might involve techniques to loosen or remove scar tissue that’s causing the bend.
II. Tunical plication: In case of mild chordee, 12 o’clock tunical plication may be enough to correct residual chordee if it was not done earlier.
III. Corporotomies: We use Corporotomies in selected redo hypospadias where they were not done earlier in the primary surgery.
IV. Grafting procedures: In some cases, surgeons might use dermal grafts from other tissues to add support and straighten the penis.
V. 16 dot plication: Dorsal plication on either side after lifting neurovascular bundles using non-absorbable sutures. This is the preferred approach in adults who have residual chordee.
The success rate of corrective surgery for residual chordee can be high, but it depends on various factors like the severity of the curvature and the expertise of the surgeon.
5. Dehiscence:
What is dehiscence after hypospadias surgery: Dehiscence after hypospadias surgery refers to the complete separation or opening of the surgical site on the penis, specifically where the doctor closed the urethra and formed the new urinary opening (meatus). There are two main types of dehiscence after hypospadias surgery:
a) Glans dehiscence: This occurs when the tissues on the head (glans) of the penis that were closed together to create the new urinary opening separate. This occurs when excess tension is on the glans after reconstruction.
b)Complete dehiscence: This means complete breakdown of the surgical repair. This a major complication and implies that further major surgeries would be needed, fortunately this is not very common.
The reported rate of dehiscence after hypospadias repair varies depending on factors like the severity of the hypospadias and the surgical technique used. The most obvious sign of dehiscence is the reopening of the surgical wound. There may be bleeding, spraying of urine or multiple urine streams.
Treatment of urethral dehiscence: Dehiscence typically requires additional medical attention. Depending on the severity, the doctor might recommend:
c). Wound care: This could involve cleaning and dressing the wound to prevent infection and promote healing.
d). Antibiotics: If there’s an infection, antibiotics will be prescribed to fight it.
e). Surgery: In some cases, additional surgery might be needed to close the wound and potentially revise the repair after 6 months.
6. Urethral diverticulum: Urethral diverticulum is a less common complication that can occur after hypospadias repair. A urethral diverticulum is a sac-like outpouching that forms along the urethra. In a normal urethra, the urethra is covered by a mass of erectile tissue called as corpus spongiosa. This corpus spongiosa encloses the urethra and acts as a supporting layer over the urethra. In hypospadias, this spongiosum may be absent or dysplastic. Due to this the new urethra after hypospadias repair may expand over time leading to urethral diverticulum.
Symptoms of urethral diverticulum can include bulge on the underside of the penis while passing urine, dribbling of urine after urination, frequent urination, urinary tract infections (UTIs), bulge in the groin or perineum (the area between the scrotum and anus) during urination which disappears after urination. Diagnosis of urethral diverticulum is usually made with clinical examination in the OPD, Retrograde urethrogram (an X-ray of the urethra) will show dilatation of the anterior urethra. Cystoscopy (a visual examination of the urethra) will show dilated urethra.
Treatment of urethral diverticulum depends on the severity of symptoms. Treatment options may include Observation (if symptoms are mild). The child or adult is asked to empty the urine by pressing on the underside of the penis everytime after urination. Antibiotics are started if there is urinary tract infection. If the diverticulum is large and causing symptoms, then surgical excision of the diverticulum with redo urethroplasty is done.
7. Penile Torsion
Penile torsion is a condition where the penis is twisted on its axis to the left or to the right. It’s a common association, particularly with distal hypospadias (occurring in up to 32.8% of cases). In most cases, the torsion is mild (less than 45 degrees) and doesn’t cause any problems. However, in some instances, it can be more severe and affect urination or appearance.
Sometimes penile torsion can occur after hypospadias repair. During surgery if the skin is pulled excessively on one side, then penile torsion can occur after the surgery. During healing after hypospadias, the penis may get twisted to one side. We have also seen some children develop torsion when a tunica vaginalis flap was not used properly during surgery
Most of the times penile torsion doesn’t cause any symptoms. If the torsion is more than 60 degrees, the urine stream may be directed to the side of torsion. Severe penile torsion may need surgical correction.
Hypospadias Foundation: Innovative individualized approach for managing failed repairs:
Of all the hypospadias surgeries at our centre, almost 40-50% are referred cases where previous surgeries have failed elsewhere. Sometimes these cases may have 2-3 failed surgeries elsewhere and rarely even 4 prior failed surgeries. Over the last few years, Dr A.K.Singal, rated as the best hypospadias surgeon in India, has developed an expertise and a special interest in managing such cases. Along with Dr Ashwitha Shenoy, top rated expert in hypospadias, the team tries to use innovative techniques for managing failed hypsopadias cases:
- Urethral fistula closure with flaps: Urethral fistula cant be taken lightly. If they are in penile region or penoscrotal region, Dr Singal and Shenoy have achieved good outcomes with VY flap or Tunica Vaginalis flap closures for such cases.
- Single stage surgery using Local skin flaps: Either parameatal flaps or random flaps. Dr Singal has presented these techniques and delivered lectures about them at various national and international conferences, and these will also soon be published in surgical books & journals as newer techniques in managing these difficult cases.
- Staged repair using buccal mucosa grafts: If the skin is very thick and scarred due to previous surgeries then best is the remove those non-healing rigid tissues from there completely and provide smooth fresh layer in first stage and this can be made into a new urethral tube in second stage. The ideal tissue for this is inner lining of cheeks or lips called the buccal mucosa. Small strips can be taken from inside the mouth (no outside cuts or stitches). This provides a smooth moist pliable tissue which has very good results when rolled into a urethral tube later on.
See Failed Hypospadias cases managed successfully at Hypospadias Foundation
Case 1- Redo Hypospadias Repair Using Flap Repair After A Failed Hypospadias Repair
Case 2- A 14 Years Old Boy – Hypospadias Cripple- Staged Reconstruction With Excellent Result
Case 3- A One-Year-Old Boy With Failed Distal Hypospadias Operated Elsewhere- Single Stage Reconstruction
Case 4- A 5 Years Old Child With Failed Hypospadias Repair Elsewhere- Single Stage Onlay Flap Repair
Case 6- A Case Of Urethrocutaneous Fistula Repair Using Tunica Vaginalis Flap
Case 7- Oral Mucosa Inlay Graft In Failed Hypospadias
Case 8- Redo Byar’s Flap Urethroplasty In Failed Hypospadias
Case 9- Flip Flap Urethroplasty For Single Stage Repair In A Case Of Redo Hypospadias
Case 12- Two Stage Oral Mucosa Graft Repair In Redo Hypospadias
Watch Video of Dr Singal & Dr Shenoy explaining treatment of failed hypospadias.