A 6-month-old boy was brought to the hypospadias foundation with a history of passing urine from the proximal penile region with downward curvature of the penis (chordee). On examination in the hypospadias clinic, the Stretched Penile Length (SPL) was 28mm and the Glans diameter (GD) was 12mm. In view of the small phallus, he received two doses of hormone injection (Injection Testosterone), which were given 1 month apart. Following the two doses, the penile size improved to SPL 32mm and GD 14mm, respectively. Considering these findings, a staged repair in proximal penile hypospadias was planned.
We planned for a two-stage hypospadias repair because the chordee was more than 45 degrees. The first stage involves chordee correction (straightening of the penis) and then urethroplasty to bring the urinary opening to the tip of the penis.
STAGE 1: CHORDEE CORRECTION AND CREATION OF BYAR’S FLAP
Step 1: Correction of chordee
The penis was degloved completely which means all the skin of the penis was completely taken down preserving its blood supply and around 50% of the chordee was corrected by degloving alone. After degloving the chordee was assessed again. Here in this case after complete degloving the chordee was found to be still more than 30 degrees. Since the chordee was significant, urethral plate was divided and proximal urethra was mobilized. Following this chordee was 20 degree and hence Tunica albuginea plication was done. Tunica albuginea plication involves placing a stitch on the top side of penis to correct the curvature. Following this plication chordee was completely corrected.
Fig 1: Clinical examination in the pre operative period showed chordee of more than 45 degrees with meatus in the proximal penile region
Fig 2: Complete degloving was done and chordee was assessed. Chordee of more than 30 degree was noted
Fig 3: Urethral plate was divided and proximal urethra was mobilized. Chordee of 20 degrees was noted which was corrected by tunica albuginea plication. No chordee was noted after plication.
Step 2: Creation of Byar’s flap
Once chordee was corrected the proximal urethra was sutured using 6-0 PDS. Byar’s flap was created. Byar’s flap involves division of the prepuce in the midline and then rotation to the underside of the penis to cover the whole underside of penis completely.
At the end of stage 1 there was a straight penis with no chordee and Byar’s flap created for urethroplasty (second stage repair).
STAGE 2: URETHROPLASTY
Prior to stage 2 flaps were assessed for the width and elasticity. An ideal byar’s flap should be wide, supple with no fibrosis. Chordee was assessed again prior to urethroplasty in stage 2.
Fig 3: Flaps wide and supple with no fibrosis
In this case, the flaps were very healthy. Chordee was assessed prior to stage 2 and there was no residual chordee. Stage 2 was started by marking a U-shaped incision of 1.5cm over the flaps. Local infiltration was given over the marked site. Urethral plate was fixed in the midline using 6-0 PDS interrupted sutures.
Fig 4: Chordee assessed prior to urethroplasty, no chordee noted.
Urethroplasty was done in 3 layers. First layer of urethroplasty done using 6-0 PDS continuous inverting sutures. Second layer with local tissues and left dartos flap was reinforced over the urethroplasty as a third layer. Skin was closed using 6-0 PDS subcuticular sutures.
Fig 5: Urethroplasty was completed in 3 layers.
Fig 6: Completion of urethroplasty using 6-0 PDS subcuticular sutures.
Dressing and catheter was removed on post operative day 7. Following catheter removal child passed urine in a single stream with no complications.
Fig 7: Post operative follow up at 1 month child with excellent healing and child passing urine in single straight stream with no complications.
Staged repair in proximal hypospadias
Proximal hypospadias is a condition where the urinary opening is in the proximal part of the penis. Majority of children with proximal hypospadias have associated chordee (abnormal bending of the penis). Chordee correction (straightening the penis) is the first and an important step during hypospadias repair. When this chordee is severe the hypospadias is repaired in two stages. Incomplete correction of chordee can lead to residual chordee which often worsens at puberty.
Following chordee correction, the prepuce was divided in the midline and rotated and sutured on the underside of the penis, a procedure known as Byar’s flap. This step is essential because this rotated prepuce is used to create the urethral passage in second stage repair i.e urethroplasty.
The minimum duration between the two stages is 6 months. Post-surgery children are able to pass urine in a single straight stream with less than 10% risk of future complications in expert hands.
Hypospadias Foundation
Hypospadias foundation is a centre dedicated for children and adults with hypospadias. Our dedication has resulted in excellent outcomes making it the best hospital in India and world for hypospadias. Children and adults from all over India and various countries from all over the world visit hypospadias foundation for surgical treatment of hypospadias. Every year more than 200 surgeries of hypospadias are performed at MITR hospital. Hypospadias foundation is located at MITR hospital in Kharghar, Navi-Mumbai, Maharashtra, India.
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 pediatric 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.
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For appointment kindly contact us at the contact details given below.
MITR hospital & Hypospadias Foundation, Kharghar, Navi Mumbai – Tue/Fri 4:00pm-6:00pm, Call for appointments: +912227743558/ 27744229/ 39/69 and +919324180553.
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