fistula repair hypospadias Archives - Hypospadias Foundation

Chordee is a condition where the penis is curved downward. Most of the times it is associated with hypospadias but can occur without hypospadias. Chordee correction is very crucial step during hypospadias repair. Without chordee correction, urethroplasty should not be attempted because there will be a stress of the urethral passage and there is high risk of complications after surgery.

Chordee surgery is usually successful in correcting the curvature of the penis completely. However, there is a small chance that chordee can come back after surgery. This is called recurrent chordee.

Risk factors for recurrent chordee:

Incomplete correction of chordee: When the chordee is severe, it must be corrected completely during chordee correction surgery. If there is any residual chordee after chordee correction surgery, it will only worsen in the future.
Fibrosis during healing: After chordee correction, fibrosis can occur on the underside of the penis during healing process. Sometimes the fibrosis can improve with steroid massage but if it persists then recurrent chordee correction may be required. This fibrosis can be at the level of skin, tissue under skin or even urethra.
Due to flaps: Recently we have seen some cases where tunica vaginalis flaps were used for second layer cover during hypospadias surgery at other centres. Somehow the flaps didn’t heal well and they caused chordee to come back. Similar outcomes we have seen when a very tight urethra was made from prepucial flaps or koyanagi repair in first surgery.

Symptoms of recurrent chordee:

The common symptoms which children present with are downward bending of the penis, urine which goes backward and may have occasional pain during erections.

Adults with recurrent chordee may have pain during erection, inability to perform sexual intercourse, painful sexual intercourse and infertility

Treatment for recurrent chordee:

If you think you may have recurrent chordee or your child has recurrent chordee, it is important that you see a doctor right away. You need to visit a hypospadias surgeon or a pediatric urologist who has expertise in the field of hypospadias and chordee correction.

Chordee correction can be done by various methods. First and foremost, the cause for recurrent chordee has to be identified and then appropriate method is used to correct chordee. Chordee correction method differs for children and adults.

If a child presents with residual chordee due to incomplete chordee correction in the past, then the following methods of chordee correction are used: Complete degloving is done and chordee is assessed, if chordee persists even after degloving then the following methods are adopted. If the chordee is due to short urethra due to flaps or tunica vaginalis flaps, we divide them at this stage.

Recurrent chordee treatment in Navi Mumbai

Pre degloving and post degloving chordee assessment

(a) Dorsal tunica Albugenia Plication (TAP): If the chordee is less than 30 degree then it can be easily corrected by placing a non-absorbable suture at the site of maximum curvature on the dorsal side(upper side) of the penis. This will correct the chordee completely.

Post Degloving showed less than 30-degree chordee. 12’o clock dorsal tunica albuginea plication done. Chordee completely corrected by this plication.

No chordee noted after 12’o clock dorsal tunica albuginea plication

(b) Urethral plate division and Proximal urethral mobilization: If the chordee is more than 30 degrees then one of the reasons for persistent chordee is short urethra, in these cases we will have to divide the urethral plate ventrally and mobilize the proximal urethra. This will effectively correct chordee if it is due to congenital short urethra.

Urethral plate division and proximal urethral mobilization

(c)If chordee persists inspite of urethral plate division then urethral mobilization, ventral corporotomies are done. This will correct the chordee if the cause for chordee is due to disproportionate corporal bodies.

Three ventral corporotomies

(d) If none of the above measures can correct chordee then we perform a ventral lengthening procedure called as the dermal graft. Deep incision is given in the tunica on the ventral side at the site of maximum curvature and dermal graft is placed at the site. This method is adopted in cases of severe chordee.

Dermal graft

The chordee is corrected completely after the above steps of chordee correction.

2. If the child presents with severe chordee inspite of complete chordee correction in the past, then it is most likely due to ventral fibrosis. In these cases, along with some or all the above methods, removal of fibrotic tissues from the underside of the penis is important to correct the chordee.

Adults with recurrent chordee after previous surgery

In most of the adults at first we assess the fibrosis and degloving is done. If the chordee is still there, then we divide the urethral plate and mobilise it. Post this, if the chordee still persists, we can correct chordee completely by a method called as “16 dot plication”. In this method, 4 sutures are placed on either side of maximum curvature on the dorsal side, which will correct the chordee uniformly in an adult penis.

In most of the cases of recurrent chordee in addition to chordee correction, urethroplasty will also be required. In redo cases, chordee correction and urethroplasty will most likely be done in two to three stages and oral mucosa graft will be used in more than 95% of such cases. Only in few exceptional we may be able to repair everything in single stage.

About Hypospadias Foundation India:

Hypospadias Foundation in Navi Mumbai, India is dedicated to offering care and cure for chordee and hypospadias in children and adults. Set up in 2008, more than 3000 children and adults have benefitted from care and achieved best in class results for chordee and hypospadias. Dr A.K.Singal and Dr Ashwitha Shenoy, hypospadias expert surgeons at Hypospadias foundation have dedicated their lives to the art and science of hypospadias repair.

If you feel your child or you are suffering from recurrent chordee even after previous chordee correction, then do get it checked by an expert pediatric urologist or a hypospadias surgeon. Chordee correction surgery has good result when done in childhood than in adulthood. Do not hesitate to write to us or contact us

Contacting the Hypospadias Foundation:

Website: https://www.hypospadiasfoundation.com/
Email: hypospadiasfoundationindia@gmail.com
Phone:
- +916262840940
- +916262690790
- +919324180553(whatsapp and teleconsult)

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

Keywords: recurrent chordee, residual chordee, chordee repair, chordee repair surgery, chordee correction surgery, bent penis repair, best hospital for hypospadias in india, best hypospadias surgeon, hypospadias repair in india, adult chordee repair, dermal graft repair, 16 dot plication for chordee

To contact Hypospadias foundation, you can either write to us at hypospadiasfoundationindia@gmail.com or fill up this contact Form

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

Hypospadias remains the most common urological abnormality affecting more than 1 lakh kids in India alone (based on incidence of 1/150 in newborn boys). Leaving aside very minor hypospadias without chordee- almost 70-80% of these require hypospadias treatment in form of repair surgery in early childhood.

For a child with Hypospadias, the first surgery is always the best surgery but still there can be complications and failure even in expert hands though complications are much less if operated by a surgeon or a centre where there is a focused practice in treating children with hypospadias. Literature and experts suggest that if a hypospadias surgeon is doing more than 50 hypospadias repairs in a year, then his results will be better and more predictable as compared to a general pediatric surgeon or a urologist who does only 10-20 hypospadias repairs in a year. Once a hypospadias surgery fails, then the next surgeries become more difficult and result more unpredictable. The failure rate of hypospadias surgeries vary from 5% to 50% depending on the type and severity of hypospadias in general centres and less than 10% in centres where hypospadias surgeries are done by expert hypospadias surgeons on a day to day basis.

Case details

Master A.P. was born with a distal penile hypospadias and underwent first surgery in Ahmedabad at the age of 6 years. Unfortunately, the surgery failed and he started passing urine from the same place on the underside of penis- a fistula. The new urinary passage through the head of the penis got tight and closed off. The surgeon tried to open it many times by catheter insertion but it failed. Coupled with failed hypospadias, the child also had an unsatisfactory cosmetic appearance in form of bunching of skin on underside of penis. With this situation they contacted Dr A.K.Singal, Pediatric urologist and expert Hypospadias surgeon at Hypospadias foundation in Kharghar, Navi Mumbai when the boy was ten years of age. After examining and confirming that the whole urinary pipe will have to be remade from distal penile region to the tip of penis (glans), Dr Singal advised a Onlay island flap repair for which the flap would be raised from the nearby bunched up skin. This repair is technically challenging because of previous failed hypospadias surgery but this was the only chance for the boy to have a single stage repair. The surgery for failed hypospadias was finished in 2 hours and A.P. was ready for discharge the next day but since they had travelled all the way from Gujarat, they decided to stay for 7-8 days in Navi Mumbai. The catheter was removed on day7 and he passed urine well from the tip. For the first one month after surgery, there were some chances of new opening getting tight, hence we taught the boy to insert a small catheter just 1cm into the new opening with an antibiotic ointment. The penis healed well in next 3 months and he has remained free of all symptoms now for last 5 years. At 15 years of age and after his 10^th standard exams, A.P visited us and had a big smile on his face. He is looking forward to higher education and he shared with us his dreams and further education goals. We plan to see him again one last time at 18 years of age. His penis growth and his functional & cosmetic outcome has been excellent so far.

Dr A.K.Singal with the patient

Letter of thanks from the father:

Dear Dr Singal,

My son A.P was operated first at Ahmedabad. The hypospadias problem was not solved and it actually worsened and we were very tense my son’s future life. While searching through internet I came to know about you and your colleague doctors.

From your past surgeries and mastery about Hypospadia surgeries we decided and contacted you before surgery. At Mitr hospital, from the first meeting with you, we were confident about our son’s second Hypospadias surgery and we decided to do it only with you.

At Mitr Hospital, we experienced very good pre and after surgery treatment from Doctors and staff also, very good and polite staff. At Gujarat we don’t have such experienced and professional hospital staff. I think this is also very important besides doctors. I feel that if the doctors are not confident they must not try and go ahead for these type of surgeries because once it is fails, the situation of patient and his family is unbearable. It creates psychological problems also and these can be very stressful to handle. Thanks to your team, my son is doing well now.

Regards

M.P., Gandhinagar, Gujarat.

About Failed Hypospadias repair:

When the hypospadias surgery fails, it is a moment of distress and lot of anguish for the parents. Even the doctors feel terrible because they know that even a hypospadias surgery which has been done well doesn’t mean that everything will heal also well. There are many variable factors which affect healing and hence, complications of hypospadias surgery happen sometimes even in best of hypospadias surgeon’s hands. The only difference being that when an expert hypospadias surgeon does the surgery, the chances of complications decreases drastically. And even if the complications happen, they can be managed well without any panic or long lasting impact.

The complications which may need second surgery are: urethral fistula, tight urethra (stenosis or urethral stricture), residual curvature (chordee), dehiscence (complete breakdown or partial breakdown), diverticulum, penile torsion or an unsatisfactory cosmetic outcome. Once it is ascertained that a second surgery is indeed needed for hypospadias, it is important to wait for 5-6 months before planning the next surgery.

About Dr A.K.Singal

Dr A.K.Singal is a well known Pediatric Urologist and one of the best hypospadias surgeons in India. Every year under his care in Mumbai, Thane and Navi Mumbai, more than 150 children undergo hypospadias treatment. More than 50 of these are children who have failed hypospadias surgery done elsewhere. With his deep understanding and experience, Dr Singal and his team are able to offer care and cure to these children. He can be contacted at hypospadiasfoundationindia@gmail.com or you can call his Assistant Doctor – Dr Rajkumar at 98212161448 if you wish to take a second opinion for a failed hypospadias surgery. Else you can fill up this contact form:

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Tag Archives: fistula repair hypospadias

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Successful result in a failed hypospadias repair: Boy from Gandhinagar (Gujarat) visits Hypospadias Foundation for a follow-up 5 years after surgery