6-year male child presented with complaints of passing urine from the underside of penis and incomplete foreskin. On clinical examination the meatus was at the distal penile region with shallow glans and mild chordee. He also had congenital defects in the foreskin. He was planned for a single or staged hypospadias repair based on the degree of chordee.
Pic 1: Clinical examination in the preoperative period showed congenital defect in the dorsal prepuce with distal penile meatus
Marking of the degloving incision was done. Local anaesthesia with adrenaline was infiltrated at the marked incision site. Complete degloving was done and chordee was assessed using artificial erection test. Mild chordee of less than 30 degree was noted. Chordee correction was done by 12’o clock tunical plication on the dorsal side. Chordee was completely corrected by this method hence we planned to go ahead with single stage repair.
Since, the glans urethral plate was shallow, a decision was made for doing a split prepucial onlay flap urethroplasty. Thinned out urethra was laid open. Dorsal prepuce was divided in the midline. Prepuce from the right half was used for urethroplasty. Required length of the prepuce was marked. Mobilization of this prepucial flap was done maintaining the vascularity along with dartos flap. Glans wings was mobilized. The prepucial flap was rotated to the underside of the penis for making a new urinary pipe. Urethroplasty was done over a 7Fr Infant feeding tube with 6-0 PDS continuous sutures on either side. The dartos tissue was spread fixed and sutured on either side to cover the suture lines using 6-0 PDS. Glansplasty was done using 6-0 PDS. Glans epithelium was closed using 6-0 PDS. Skin was closed in 2 layers using 6-0 PDS and 6-0 Vicryl rapide. Dressing change was done on 7th day. Post operative day 16, the dressing and catheter was removed.
Pic 2: Complete degloving done to assess chordee.
Pic 3: Artificial erection test done and mild distal chordee of less than 20 degrees noted. Chordee correction done by 12’o clock dorsal tunica albuginea plication. No chordee after dorsal tunical plication.
Pic 4: Split prepucial flap raised with good dartos tissue and glans wings widely raised
Pic 5: Onlay flap urethroplasty done over 7Fr IFT with 6-0 PDS
Pic 6: Glansplasty done using 6-0 PDS. Skin sutured in 2 layers using 6-0 PDS and 6-0 vicryl rapide
Pic 7: Cosmetic result at 1 month after surgery with single straight stream of urine
Single stage repair of mid penile hypospadias with split prepucial onlay flap urethroplasty
Mid-penile hypospadias is a type of hypospadias where the urethral opening is located on the middle of the underside of the penis and is usually associated with chordee. Corrective Hypospadias Surgery is typically the recommended treatment for mid-penile hypospadias. The goal of the surgery is to create a new urethra, straighten the penis (correct chordee) and improve the appearance of the penis.
Surgery can be done in single or two stages. This decision is taken during the surgery depending on the degree of chordee. If the chordee is less than 30 degrees, then chordee correction and urethroplasty can be done in one stage. The surgical options available are prepucial onlay flap urethroplasty or Tubularized incised plate urethroplasty.
Prepucial onlay flap urethroplasty is a surgical technique used to correct hypospadias using a flap of skin from the foreskin (prepuce) to create a new urethra. A flap of skin is created from the foreskin. The existing urethral bed is prepared to receive the flap. The skin flap is positioned over the urethra and sutured into place. Glans is closed and the remaining skin is closed to form the new penis.
Traditional Long onlay flaps can result in diverticulum formation as one of the common complications. Also, there may be instances of penile torsion. To overcome these challenges, we typically limit the flap repairs to the distal or mid penile hypospadias.
Dr Singal and Dr Shenoy have worked on a new variation of onlay flap urethroplasty to prevent these complications. The flap is made once the dorsal prepuce is split in middle and rotated down. This prevents the complication of penile torsion. Also, cosmetic result becomes better. The maximum length available in this flap is typically 2 cm. Hence Singal-Shenoy hypospadias repair is suitable only for distal/ mid penile or sometimes proximal penile hypospadias.
About Hypospadias Foundation
Hypospadias Foundation located in Kharghar, Navi Mumbai, Maharashtra is the topmost centre in India and one of the leading centres in the world for hypospadias treatment. Children and adults not only from India but from all over the world visit and get treated successfully at hypospadias foundation. Over the last 15 years we have been performing more than 200 surgeries per year with complication rate of less than 5%. Our expertise in this area has helped us achieve the success in this field.
Dr A K Singal is a top and expert surgeon who has dedicated his life in treating children and adults with hypospadias. He is rated as one of the best hypospadias surgeon in India and the world.
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. Working together, their dedication and expertise in this area have helped us achieve excellent outcomes in adults and children with hypospadias.