chordee Archives - Hypospadias Foundation

February 02 2014

Cost of Hypospadias Surgery in India

Hypospadias is a very common birth defect affecting up to 1/150 newborn baby boys. In the current era most of the couples choose to have one or maximum two children and that too with a lot of planning. The moment the newborn baby boy is diagnosed to have hypospadias – besides distress and worry for the baby’s health and future parents also start worrying about other things. These are:

When should the surgery be done
Where and by whom should the surgery be done
What will be the long term outcome after surgery
How much is the hypospadias repair surgery going to cost

While the first three questions have been answered elsewhere, the last question forms the substance of this blog. Parents always worry ” Is hypospadias repair surgery going to be very expensive?, Would my insurance policy pay for hypospadias surgery since hypospadias is a birth defect”

The cost of hypospadias repair surgery varies according to the type & severity of the hypospadias, type of surgical technique, time taken by the hypospadias surgeon, assistant used or not and finally type of room taken- general ward or shared room or a single deluxe room.

Elaborating further – for a mild variety of hypospadias like glanular/ distal penile hypospadias with mild chordee, an expert hypospadias surgeon will take under one hour for surgery, work without assistant surgeon and the charges may start from 1000 US Dollars (60,000 Indian rupees) while for a severe hypospadias such as scrotal/ perineal hypospadias the charges may go upto 3500 US dollars (2,00,000 Indian rupees) for a single stage urethroplasty.
Some of the hospitals in Mumbai may be more expensive than say for example Hypospadias Foundation at MITR Hospital in Navi Mumbai.
For some of the severe hypospadias a staged urethroplasty repair may be needed and then the budget may extend further but this happens in less than 5% of the cases. Though at Hypospadias Foundation located at MITR Hospital in Kharghar, Navi Mumbai, majority of our hypospadias repair surgeries are single stage urethroplasty surgeries, still in 4-5% of the children referred to us, the hypospadias may have a very severe chordee necessitating a two stage approach for better long term outcomes.

Hence, the actual charges of hypospadias repair can only be decided after a full hypospadias examination and discussion with the parents face to face.

Similar hypospadias surgery in USA carries upto ten times the charges and maybe 5-6 times of Indian charges in Europe. When looked at in context of India, though most of the families are able to afford these expenses, for some indian families these may still be high. Some of these families get support from Hypospadias Foundation either as medical consumables support or by way of some discounts in surgeries at Hypospadias Foundation. We have tried to ensure a policy of NEVER Saying NO to a child with hypospadias for economic reasons. If the intent is right, money comes in as Donations etc.

Coverage of Hypospadias by Insurance Companies:

Hypospadias being a birth defect is generally not covered by most of the insurance companies in India atleast while in USA, UK it is covered under insurance benefits. Some of the corporate insurance group covers do include all pre-existing as well as birth defects for their employees and hence hypospadias repair procedure may be covered by the insurance company by some of these companies.

In the other cases, the parents usually end up paying up these charges by themselves out of their own pocket. For new parents working in a job or middle class environment this may be stressful. What helps is that Hypospadias repair surgery is a planned procedure. It can be done anytime between 6 months-15 months of age giving parents enough time to rally around and arrange everything from money to other resources. Hence, it is best that they meet a hypospadias expert or a pediatric urologist early on in first 1-2 months and then learn everything about the charges, hospital stay, pre-hypospadias surgery tests and then get mentally prepared for the actual surgery.

Please feel write to us for an opinion at hypospadiasfoundationindia@gmail.com or fill this contact form Contact Hypospadias Foundation

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February 02 2014

Goals of Hypospadias Repair Surgery

Before we talk about goals of hypospadias surgery, let’s understand the issues in uncorrected hypospadias.

Anatomical defects in Hypospadias: Hypospadias encompasses two basic structural defects in the penis- abnormal location of the urinary opening and chordee (bend in the penis). Another minor defect is incomplete foreskin (prepuce) which does not lead to much cosmetic or functional impairment. We regularly use prepuce and its internal tissues for performing a strong structural hypospadias repair, hence circumcision most often is a part of the procedure.

Functional issues in Hypospadias: Functionally, penis has two important aspects:

Ensure Smooth uninterrupted flow of urine-possible by a wide caliber of urethra
Sexual organ for intercourse and also for passage of semen for fertility

Except in minor hypospadias, in all moderate to severe hypospadias both these functions are impaired unless corrected.

Cosmetic deformity in Hypospadias: Last but not the least, except for very minor hypospadias without chordee – all the other hypospadias lead to significant cosmetic deformity which most of the teenagers and adults would not accept as normal. Genital perception is important in overall normal development of the child into a balanced teenager and adult later on.

Goals of Hypospadias repair: Hypospadias surgery procedure (urethroplasty) mostly in single stage and rarely in multiple stages (depending on the severity of hypospadias) aims to correct these structural defects, impart a good functional outcome both from urinary perspective all throughout life and later in adulthood for sexual purposes with a good cosmetic appearance.

Hence, when doing the hypospadias correction, a hypospadias expert surgeon keeps all these goals in mind. The stepwise approach with a standardized protocol helps in achieving all these goals. Over the last two decades, lot of research and dedicated best hypospadias surgeons have made sure that the anatomy and functional aspects are taken care of in an appropriate manner with long lasting good outcomes.

Stepwise standardized hypospadias surgery protocol

(As practiced by Dr A.K.Singal, Pediatric Urologist & Hypospadias Expert)

After nearly 7 years of dedicated hypospadias surgeries, we and other top hypospadias surgeons have realized that it is very important to follow a standardized approach as follows:

Examination under Anesthesia with magnification: The clinical examination done in outpatient department may not have been sufficient. Re-examining the child under anesthesia in detail while wearing magnifying loupes allows a hypospadias surgeon to create a mental roadmap. While scrubbing, draping, painting this roadmap provides a reliable navigation and focus to achieve best results during hypospadias repair.
Marking of skin incisions and injection of anesthetic agent with adrenaline: We routinely as a first step mark the incision sites and then inject dilute xylocaine and adrenaline and then wait for five minutes. This prevents minor bleeds from the hypospadias surgery site and keeps the area clean. This also allows decreases the use of electrocautery to stop the bleeding to a minimum.
Degloving the penis: Incisions are deepened preserving the nerve and blood supply to penis and whole skin of the penis is taken down – a step called degloving. This is done in all l hypospadias surgeries and most of the times is enough for correction of the chordee. The penis is carefullu delgoved preserving the urethral plate. Till this time, the technique of hypospadias repair is still not decided.
Chordee correction: Once penis is completely degloved, an artificial erection test is done to make sure that the penis is straight else various types of chordee correction procedures can be done. Straightening of the penis is the prerequisite for any type of urethroplasty and a surgeon should not move ahead with urethroplasty till chordee correction is satisfactory.
Deciding the technique of Hypospadias repair (Urethroplasty): After chordee correction, anatomy is assessed again. If the hypospadias is not very severe and the urethral plate (tissue between urinary opening till the glans) is wide, soft and elastic- a Tubularised Incised plate urethroplasty (Snodgrass repair) can be done). In a proximal hypospadias or a poor urethral plate, onlay island flap repair should be done. If the skin just below the urethral plate is good, then a Mathieu’s flip flap repair can also be done. If the urethral plate has been transected to correct the penis curvature then a precpucial tube repair should be considered or a staged hypospadias repair can be done.
Second layer coverage to prevent fistula: A second layer cover over the new urethra is very important to prevent urethral fistula post hypospadias surgery. This can be taken from surrounding spongiosum, dartos fascia from prepuce or tunica vaginalis (covering of the testis)
Glansplasty and meatoplasty: Reconstruction of the head of penis is a critical component for good cosmetic result as well as to make sure the opening is wide enough to allow free passage of urine. This is ensured by wide dissection of glans and also while closing the glans new urethra should be able to accommodate a good sized catheter without tension. Meatus should be left wide and an effort is made to make it like a slit like meatus which is cosmetically pleasing.
Penile skin closure: Excess prepuce on the top of penis is split in midline and brought on either side towards underside of penis. Jacket shaped incisions are made to remove extra foreskin and then a midline suture line is created for an excellent cosmetic outcome after hypospadias repair.
Proper fixation of the catheter: Urethral catheter is fixed with a stitch taken through glans so that it stays inside. The catheter is kept for 5-10 days depending on the type of surgery and healing.
Dressing: Decade ago very bulky and tight hypospadias dressings were in vogue, nowadays we use very soft and light dressings which can be removed easily an then let the catheter drain into a double diaper.

Following these sequential hypospadias surgery steps and a standardised protocol over last few years in more than 500 kids, has led to faster surgery, shorter anesthesia times, lesser bleeding, better cosmesis and extremely low rates of complications after hypospadias surgery at Hypospadias Foundation. And most importantly, this has also made sure that all the goals of hypospadias surgery are properly met.

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June 06 2012

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

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Tag Archives: chordee

Contact Form for Hypospadias Foundation

Contact Form for Hypospadias Foundation

Contact Form for Hypospadias Foundation