chordee correction Archives - Hypospadias Foundation

April 04 2021

Single Stage Repair Surgery for Distal Hypospadias and Penile Torsion

Hypospadias Foundation starts Clinic for Hypospadias Treatment & Surgery in Bahrain

A 10-month-old child was brought with complaints of deviation of urine stream and abnormal location of meatus. On clinical examination, there was distal penile hypospadias with severe penile torsion measuring 90 degrees to the left. We planned a single-stage correction for both Surgery for Distal Hypospadias and Penile Torsion, addressing both conditions simultaneously to optimize outcomes efficiently.

Penile torsion

Notice Penile torsion to left

Distal Hypospadias with Penile torsion

Surgery Steps:

Marking of the degloving incision, a crucial step in surgery for distal hypospadias and penile torsion, commenced the procedure. Local anesthesia was meticulously infiltrated at the marked incision site to ensure patient comfort. The surgical process proceeded with complete degloving and assessment of chordee, revealing a 30-degree chordee. Chordee correction was expertly performed through Tunica albuginea plication at 12 o’clock on the dorsal side, resulting in the successful elimination of chordee. Urethroplasty commenced with precise incision of the urethral plate in the midline, followed by meticulous suturing over a 7Fr Infant feeding tube with 6-0 PDS continuous sutures. Additional measures included the harvesting of a Dartos flap for extra coverage over the urethroplasty, secured with 6-0 PDS sutures. Penoscrotal web correction was also addressed, with excess skin excised and meticulously sutured using 5-0 vicryl rapide. To address penile torsion, skin flaps were rotated and adjusted, ensuring optimal alignment, and meticulously sutured all around using 5-0 vicryl rapide. Postoperative care included a 7-day period with dressing and catheter in situ, followed by their removal to facilitate the patient’s recovery.

Penile torsion and Hypospadias repair

Finished Hypospadias and Penile torsion surgery

Surgery for Distal Hypospadias and Penile Torsion

Final outcome of correction of penile torsion and hypospadias

Results

The Final result was very gratifying with a straight penis without any torsion. The child was passing urine in good stream in straight axis without any discomfort or pain.

About Hypospadias repair and penile torsion

Penile torsion is a condition wherein the penis is rotated or twisted on its axis. The penile torsion is more commonly to the left. Many a time penile torsion may not be detected till a circumcision is planned or foreskin is retracted.

Penile torsion may be associated with hypospadias and/or chordee (penile curvature). With hypospadias, penile torsion is mostly associated with distal penile cases.

Based on the degree of glanular rotation, penile torsion can be classified as mild, moderate, and severe. It is mild if its less than 45 degree, moderate if it’s between 45-90 degree and severe if more than 90 degree.

Penile torsion in majority of cases (>85%) is between 10 to 20 degree. If it is a moderate or severe degree of torsion, urine stream may be deviated to one side.

Surgical intervention is not always required in isolated penile torsion. The indications for surgical correction are cosmetic, functional, or sexual. When penile torsion is associated with hypospadias, it should be corrected along with Hypospadias repair or urethroplasty at the same time.

About Hypospadias Foundation

Hypospadias foundation is a centre which provides personalized and best quality care for children and adults with hypospadias. It is one of the best hospital centres in India and world for surgical treatment for hypospadias in adults and children. Our dedication in the field of hypospadias has helped us achieve excellent outcomes in these patients. We treat children and adults not only from various parts of India but also from more than 25 countries all over the world. Hypospadias foundation is located at MITR hospital in Kharghar, Navi-Mumbai, Maharashtra, India. Every year more than 200 surgeries for hypospadias are performed at MITR hospital and Hypospadias Foundation

Contact us:

For appointment kindly contact us at the contact details given below.

MITR hospital & Hypospadias Foundation, Kharghar, Navi Mumbai, India
MITR Clinic: C1/8 Ground floor, Sector-2, VashiCall

Call for appointments: +91-2227743558/ 27744229/ 39/69 and +919324180553.

Or you can fill up this form- Contact form for Dr Singal

Fill up contact form: https://www.hypospadiasfoundation.com/contact/

April 04 2015

Long journey from Patna to Navi Mumbai: Severe scrotal hypospadias managed successfully at Hypospadias Foundation

Hypospadias is one of the most common urological anomalies in boys. While 80% of all hypospadias are mild and of distal or midpenile, 20% are proximal hypospadias. Severe varieties like scrotal hypospadias form only 5% of total burden of hypospadias. Severe hypospadias such as scrotal hypospadias often have associated chordee (bent penis) and this may be very severe too posing a challenge for the hypospadias surgeon. We have realized in last few years that making the penis straight (chordee correction) is THE MOST IMPORTANT step of hypospadias repair procedure. While most of the severe scrotal hypospadias are also repaired in a single stage (almost 90% are suitable for a single stage urethroplasty), in 10% of the children the anomaly is so severe especially due to severe chordee that two stage repair may be better for an optimal long term outcome.

Master R.P. was born with scrotal hypospadias, severe chordee in Patna, Bihar and was advised to undergo surgery after 1 year of age. The parents went to multiple doctors in Patna, Delhi and finally came to consult Dr A.K.Singal, renowned Hypospadias surgeon at MITR Hospital, Navi Mumbai. On examination, the child had a severe scrotal hypospadias, severe chordee (almost 90 degrees) and abnormally fused skin of scrotum to the penis. This almost looked like a trapped hypospadias penis due to skin shortage. Dr Singal discussed in detail with parents that such a severe hypospadias may require hypospadias treatment in stages. Due to the severity it may be impossible to correct all the defects in one surgery. Also the penis length may have got shortened and cosmetic result would also been suboptimal.

Finally, R.P. was taken under anesthesia and hypospadias repair surgery was started. As a first step the penis was degloved. Urethral plate was divided and the fibrous bands causing chordee on the underside of penis were divided deeply till the scrotum. The penis was almost straight after this maneuver with just 30 degree bend which was further corrected by a placing a placating stitch on the top side of penis (tunica albuginea plication or TAP). Artificial erection test confirmed the complete correction of chordee. Since the chordee was severe and the urethral plate was also divided, single stage surgery would have carried very high failure rates. Hence, a staged urethroplasty was planned. The skin on the top of the penis was divided in midline and brought to the underside of penis. A part of the skin was advanced into the head of penis (glans) so that the new urethra in next stage would be constructed till the tip of penis. This is called Thiersch Byar’s urethroplasty stage-1. There was a compression dressing done which was removed after 7 days and the family travelled back to Patna after a total of 14 days after first hypospadias surgery.

Happy family with Dr Singal after Surgery

The family sent us some pictures in the healing phase over next few months and the second stage urethroplasty was planned after 6 months of first hypospadias surgery. When we saw the patient again – the flaps and the skin on the underside was very well healed and ready for second stage. Second stage urethroplasty was done and it took just 2 hours for the surgery. The catheter was removed after ten days and the R.P. passed urine in a good stream from the tip of the penis like a normal boy. Family was delighted and after another follow-up visit one week later they travelled back to Bihar.

According to Dr Singal, “With the experience and expertise, currently we do single stage surgery for even scrotal hypospadias and other complex hypospadias. The only limiting factor is the severity of the chordee. Sometimes in sever chordee we need to apply a cut on the underside of penis to straighten it. In such cases, it is better to do a staged repair. In our experience, two stage hypospadias surgery can have excellent cosmetic and functional results. It also provided a longer penis length by straightening the penis and elongating the underside of penis when chordee correction is done.

About the author:

Dr A.K.Singal is a senior Pediatric Urologist and a renowned Hypospadias expert surgeon in Navi Mumbai, India. Every year he operates more than 200 kids and adults with hypospadias from all over the world and from all over India. Dr Singal has done lot of clinical research and conducted training programs for hypospadias surgery in India. Due to expertise in managing complex cases of severe hypospadias and failed hypospadias operated elsewhere, he is counted as one of the best and top hypospadias surgeons in India.

Dr A.K.Singal delivering his talk at ESPU

About Hypospadias Foundation:

Hypospadias Foundation is World’s first and only organisation dedicated to care and cure of children and adults with hypospadias. Started in 2008 by Dr Singal and Dr Dubey, more than 1000 patients have benefitted from care at the foundation from more than 20 countries. The blessings and goodwill only continues to grow from a single point focus of excellence in hypospadiology. The foundation soon intends to start formal training courses in Hypospadias surgery for international doctors.

To contact us you can

Email us at hypospadiasfoundationindia@gmailcom

Or Call Dr Rajkumar, Coordinator, at +91-9821261448 between 10am-4pm.

Else you can fill up this form: Contact Hypospadias Foundation

Watch video of Scrotal hypospadias surgery repair by Dr Singal

Watch video of Proximal penile hypospadias surgery by Dr Singal

Contact Form for Hypospadias Foundation

Please fill all clinical details and upload pictures and clinical summaries (if available)

April 04 2015

What is chordee (bent penis) and why do hypospadias have chordee? How is chordee correction surgery done?

Chordee means that the penis is bent (curved penis). Penis mostly gets bent downwards hence it is called ventral chordee and is seen commonly seen in children with hypospadias. In children with other type of anomaly which is much rarer than hypospadias called epispadias the penis may be bent upwards, it is called dorsal chordee. Hypospadias is atleast 20-30 times more common than epispadias, hence when someone uses the word chordee it is by fault supposed to mean ventral chordee as seen in hypospadias.

Why does chordee happen?

When the penis is getting formed between 8-12 weeks of pregnancy, the urethra (urinary passage) also starts getting formed from the base of penis to the tip of penis. This happens gradually under the 3influence of male hormones produced by the testis. All around urethra, a special tissue called corpus spongiosum is also formed through which the urethra runs. The two cylinders of tissue called corpus cavernosa are also formed. Together equal sizes of spongiosum and two cavernosa cylinder are responsible for a straight penis. When the urethra is short as in hypospadias, the spongiosum tissue is a3lso short, the skin and dartos tissue under skin is also short and sometimes the corpora can also be curved. Hence chordee results from this shortage of these tissues on underside of penis.

Do all hypospadias have chordee?

Chordee is seen more than 50% of all hypospadias but this also depends on the severity of hypospadias. Generally, the more severe the hypospadias is, higher the chances of chordee. Hence, chordee is more common in scrotal hypospadias than distal penile hypospadias. This is a generalization and it is not true in all cases as we have seen lot of cases of chordee without hypospadias and also minor hypospadias having a major degree of chordee.

How is chordee checked and graded?

Chordee can sometimes be seen by the parents when the child has an early morning erection which happens even in small babies. Generally we tell the parents to click the picture from the side to document the chordee degree. Chordee must always be checked during hypospadias surgery by doing an artificial erection test. This is infact a mandatory test for all hypospadias and the most important thing to be taken care of during hypospadias surgery. If chordee is not checked and left untreated, it can create lot of issues in adulthood and need surgery again which is much more difficult in adulthood. Chordee is graded in degrees like 30 degrees, 45 degrees or 90 degrees or also as mild, moderate or severe.

Does chordee always need surgery repair?

A straight penis is important to have straight stream of urine as well as for having normal sexual intercourse. Hence, if the penis has anything more than 15-20 degrees of bend should be corrected.

How is chordee repair surgery done?

Degloving of penis: In any hypospadias surgery or chordee repair surgery, the first step is called degloving of penis. Degloving means that the penis skin is taken down till the base of penis by a circular incision around head of penis while saving the opening of hypospadias and urethral plate. Generally, there are some abnormal tissues around base of penis which cause chordee and once these are divided chordee gets corrected in most cases. Then a tourniquet is applied on the base of penis and saline solution is injected into the head of penis or corporal bodies. This is called artificial erection test and allows the hypospadias surgeon to assess the degree of chordee.
Tunica albuginea plication: If there is still chordee then further steps need to be done to correct chordee. If the chordee is mild, then we perform tighten the top side of penis with a non-absorbable stitch to straighten the penis.
Division of urethral plate: If the chordee is still severe then a cut needs to be given to divide the urethral plate between hypospadias opening and the head of penis.
Dermal graft for chordee correction: Chordee is again checked and if it still severe then corpora needs to be lengthened by placing a dermal graft on underside of penis. In case a dermal graft is placed, then a single staged repair can’t be done and a staged hypospadias repair is done.

It is important for a hypospadias surgeon to make sure that the chordee is completely corrected during hypospadias surgery. It requires experience to do a stepwise assessment of the chordee in every individual case and then proceed with chordee repair as detailed above. The importance of having a straight penis cannot be overemphasized.

About the author:

Dr A.K.Singal during Hypospadias surgery

Dr A.K.Singal is a renowned Pediatric urologist and is one of the best & most experienced hypospadias surgeons across India and world. His deep interest, research, knowledge has helped hundreds of children and adults with hypospadias achieve a satisfactory cosmetic and functional results of hypospadias. Dr Singal is available in Fortis Hospital in Mulund Mumbai, Jupiter hospital in Thane, Fortis Hospital in Vashi (Navi Mumbai) and MITR Hospital & Hypospadias Foundation in Kharghar, Navi Mumbai, India. To reach him you can send him an email at hypospadiasfoundationindia@gmail.com or fill up this form:

Contact form for Dr Singal

Also, you can call up Dr Rajkumar, Dr Singal’s assistant and Coordinator of Hypospadias Foundation on +91-9821261448

Video of Glanular Hypospadias with chordee surgery repair by Dr A.K.Singal

Video of Distal penile hypospadias repair procedure by Dr A.K.Singal

Video of proximal penile hypospadias repair surgery procedure by Dr A.K.Singal

Video of scrotal hypospadias single stage repair procedure by Dr A.K.Singal

Please fill all clinical details and upload pictures and clinical summaries (if available)

June 06 2014

Checklist before Hypospadias Repair Surgery

Hypospadias Foundation starts Clinic for Hypospadias Treatment & Surgery in Bahrain

Hypospadias is a birth defect which affects a vital organ of the body- Penis. Penis is the most important organ for urinary and sexual function in a male. Though everyone worries more about sexual function, let me tell you as an expert hypospadias surgeon and a pediatric urologist that both urinary and sexual functions are equally important. While we may need penis for sexual function may be once or twice a day and for maybe for 30-40 years in our lives, we certainly need it for urinary function right from birth till we die and many more times each day. Hence the purpose of hypospadias repair is to set both the functions right in one go- single stage urethroplasty. This includes correction of the curvature of the penis (chordee correction) as well as making a good caliber smooth new urethra till the tip of penis.

But all said and done – Hypospadias treatment means a surgery. Surgery word itself is very scary and it requires a lot of courage and faith for the parents to handover their little one to a surgeon and let me tell you it is not easy for parents to hand over their young kid for a surgery. Lot of things go around in their minds about risks, results and safety of both surgery and anesthesia. Having been a pediatric urologist for almost a decade now, I can feel their helplessness and pain. I never let these feelings overpower me and become a stumbling block to delivering good care. I try to channelize them in the right way and empathize with the family and tell them upfront that I know how they are feeling. And then I tell them what all safety precautions and risk mitigation strategies we have lined up for the hypospadias surgery. My favorite sentence at this juncture is “Safety first everything else later”.

An helmet/ bike analogy works well in this situation: we should always follow all precautions before we go for a bike ride and most importantly wearing a helmet. We may wear a helmet a thousand times and not have an accident but the day we don’t wear it that is the day when we are vulnerable and if something happens- it will be life threatening. Similarly, while doing a hypospadias surgery on a small kid we also take all precautions to make sure that we are absolutely prepared even if something happens in that rare 1/1000 chances.

Hypospadias Surgery Checklist:

Pre-operative fitness tests: A thorough history is taken for any evidence of infection, other illness and any familial disorders. A complete blood count and a urine test is done to check for body parameters. A pediatrician consult is often taken for a systemic examination. Chest xray is no longer recommended routinely before elective surgery if the chest examination is normal.
Pediatric Anesthesiologist: An anesthesia doctor adept at handling kids and regularly giving anesthesia to small kids is the second most important team member after the pediatric urologist.
Hypospadias surgery set: Hypospadias repair surgery require fine, sharp and specialized microsurgery instruments- we keep is separately as a “Hypospadias Set” which is not used for any other surgery.
Operation theatre: OT needs to be clean, sterilized, have all safety equipment for anesthesia, good lighting and all possible infection control measures.
Antibiotic dose just before surgery: We give a dose of injectable broad spectrum antibiotic just before starting the surgery as an infection prevention measure.
Trained staff: Well-trained nursing and junior doctor staff is needed both while assisting surgeries as well as post-operative management, since at Hypospadias foundation at MITR Hospital, Navi Mumbai, India- we do more than 150 hypospadias repairs every year- even the ward assistants know the care of these babies after surgery.
Standardised protocol of surgery: This has been covered in another blog- read it here.

As a Pediatric Urologist and Hypospadias Specialist, I feel overwhelmed when parents trust me and handover their little ones under my care. It is a big responsibility and I try my best to handle them with care. Trust and faith that everything will be fine goes a long way in finding a cure for hypospadias. After all we are all instruments of god trying to do our best. As long as the intentions and efforts are honest, the results will also be good.

About Dr A.K.Singal: Dr Singal is a renowned and top pediatric urologist & one of the best hypospadias surgeons in India. He is well known for single stage hypospadias surgical corrections. He operates children with hypospadias at his centre @ Hypospadias Foundation at Kharghar Navi Mumbai, at MGM & Fortis Hospitals in Vashi, at Fortis Hospital in Mulund, Mumbai and at Jupiter Hospital in Thane.

Dr A.K.Singal during Hypospadias surgery

Please feel free to write to us for an opinion at hypospadiasfoundationindia@gmail.com or fill this contact form http://hypospadiasfoundation.com/contact-patient.htm

Watch videos on our Youtube Channel:

https://www.youtube.com/watch?v=HGRDZGXlffY

https://www.youtube.com/watch?v=M9_buN10lUE

Tag Archives: chordee correction

Contact Form for Hypospadias Foundation