Hypospadias Surgeon Archives - Page 6 of 6

July 07 2012

How to prevent failures in Hypospadias Surgery (Urethroplasty)

Hypospadias is a complex and challenging clinical problem. Worldwide accepted failure rates for single stage hypospadias repair (urethroplasty) are 5-10% and these children who have encountered a failure require a second surgery. This situation is never pleasant for the surgeon or the parents or the child who is actually undergoing another surgery. The key thing to understand here is that everyone including the parents and the doctors are on the same side in this situation and everyone wants the child to get better.

Infact when the parents come and see me in the clinic and ask about my second surgery or failure rates – I often tell them “I want your kid to have only one surgery, you want your kid to have only one surgery and the whole reason why you came to meet me and came to know that there is someone called Dr Singal is that your son has hypospadias. Our goals are, thus, aligned towards pursuing a good result with only one surgery in mind but at the same time realizing that inspite of our best intentions and experience and all the money and the efforts, 5% of the kids may still require a second surgery. Another reassuring fact is that the second surgeries are often minor with faster recovery and overall at the end of it all the child would be absolutely normal in almost all the cases. The only difficulty is to assess with full surety which child will have a failed surgery. For the child whom the second surgery becomes a reality the individual failure rate is thus 100% and for the rest the result is 100%”

Fortunately, there are some fine pointers which tell us about the increased risk of second surgery. These are:

Severe hypospadias
Severe chordee (the penis is very bent)
Associated issues like chromosomal problems or disorder of sex development.

The steps which one takes to avoid failure in hypospadias have to be titrated for each case thus giving each child undivided individual attention and care. Some of the mantras in avoiding pitfalls are:

Spending enough time to understand the subtle nuances and variations in anatomy of every case.
Proper selection of technique of surgery- single most important step in ensuring good outcome. There are over 100 techniques described for hypospadias repair. Most of the surgeons master 4-5 techniques and then for every case we have to diligently assess and assign a technique. This is best done at the time of surgery in the operation theatre. That is why a proper training, experience and dedication is very important in assuring good results. Pediatric urology training allows a surgeon to be flexible in the approach and decide at the last moment and even change the technique if something is not working out. It is akin to waiting for a ball to spin and then playing a shot called “late cut” in cricket. The whole hypospadias repair mirrors that philosophy.
A thorough re-operative assessment of the child for nutritional and health status is very important. The hemoglobin should be atleast 10gm% and the overall child should be well nourished so that the tissues will heal faster and better after surgery.
Fitness for anesthesia: Hypospadias surgeries require general anesthesia for the child. It is very important that blood tests and urine tests are normal for the child. Also, a very good clinical examination is done to make sure that the child does not have any other coexisting abnormality of infection such as chest infection, cough, cold, diarrhea or skin infection. Infection anywhere in the body makes the body weak as the body is consuming energy in fighting the infection and thus healing would be delayed. Also, there is a risk of a cross infection in the operated area. Since hypospadias is not an emergency, ideally we should wait till the child is fully well and in the “Pink of the health” (so to speak) before surgery.
Planning the surgery in a dedicated, good, well equipped & sterile operation theatre to prevent infection
Having microsurgical instruments which are dedicated only towards hypospadias repair and not used for any other surgery. Infact I personally have 3 such sets allowing me to sometimes perform 2-3 hypospadias repairs in one day
Using a magnifying loupe during surgery to perform surgery with finesse. Magnification helps in proper and fine dissection of tissues. Also the stitches used are of very fine caliber so magnification helps in tying knots properly.
Working with fine sutures- this goes hand in hand with using magnification since using magnification allows surgeon to use finer sutures.
Trained staff for surgery and post-operative care.

In the end it is important to remember that for a child with hypospadias, first surgery is the best chance at a complete functional and cosmetic result. Pediatric Urologist and the medical team should make sure and do whatever in their power to give the child a 100% result in the first stage.
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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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April 04 2012

Why nobody talks about Hypospadias?

Hypospadias is a condition where the urinary opening instead of being present at the tip of penis lies somewhere on the underside of penis. There may be an associated downward curvature of penis (called chordee) as well.

Hypospadias is a common disorder, yet it never gets much public attention. If we just talk about the hardcore data – it is staggering!!

1/200 boys has hypospadias and this translates to 30 lakh (3 million) Indians (both adult & children) having Hypospadias which has either got treated, ignored or there have been failed attempts at repair. Every year there are more than 75000 kids born with hypospadias in India. Multiply this by 4 and you will get the global scale of the problem.

Inspite of millions of kids having hypospadias and recent reports showing an increasing incidence because of various environmental factors, it is shocking that so little has been done to help children with hypospadias. Right from creating awareness about hypospadias to dispelling myths about Hypospadias and then leading on to supporting these children in younger age with proper diagnosis, timely surgery, evaluation for associated issues and then making sure that they develop into productive citizens of the society – this is a massive task. It requires motivation, commitment and understanding of the complex interplay both from the medical personnel as well as the parents of the child.

Maybe hypospadias affects the male organ, putting parents and family under pressure to hide the disorder and everyone is worried about the stigma a penile abnormality carries even if repaired. Having seen numerous children with Hypospadias and their families, I understand a bit of their side. This will improve only when society starts thinking of Hypospadias or for that matter any disorder affecting the reproductive system as a small aberration and that too fully correctable with latest treatments.

With growing experience, instrumentation, commitment and requisite team building, the results of hypospadias surgery are better than before. Hypospadias correction or Urethroplasty gets performed before infancy is over, most of the children go home the day of surgery in their diapers and success rates of a single stage urethroplasty are more than 95% over all varying from almost 99% in distal hypospadias to 90% in proximal hypospadias.

It takes years for a surgeon to hone skills which will provide a predictably good result and a standard of care. This may involve first, a medical school training (5.5 years), General Surgery training (3 years), Specialist surgery training in Pediatric Surgery (3 years) and then a Pediatric urology training (1-2 years) – so a long haul of 12 plus years and that’s not it. It takes a further of 1-2 years to establish a centre and then train the ancillary staff for managing these children.

During training when I saw the hypospadias surgery for the first time, I never thought that I would get so attached to caring for children with hypospadias. The surgery was difficult, required immense concentration for a prolonged period of time with magnification glasses and fine instruments, and still the results were suboptimal. It all changed during my Pediatric urology stint at Nationwide Childrens Hospital, Ohio-USA with Dr Rama Jayanthi. Suddenly, hypospadias was no longer a mathematical impossibility. It seemed possible to get predictable results after all and see happy kids. From then on there has been no looking back.

Operating on a child with hypospadias is still the most important task for me and it something I look forward to doing every day. It is like meditation, first surgery in the morning. Everybody is ready, the team is motivated about making a difference to a little kid and then we do our jobs with precision and in sync at MITR Hospital and Hypospadias foundation. The staff is trained in pre-operative and post-operative care.

Infact it has been the dream of my closest friend, colleague and co-founder of Hypospadias foundation – Dr Manish Dubey to see kids walking around the hospital with pink bandages on their penis and balloons in their hands and, we made it come true last year on Childrens day (14 November) when we operated 3 kids with hypospadias in a single day.

Inside everyone lies a hope, a positive current which carries us forward through our life. We also believe that with better management of the hypospadias on clinical as well incidental issues around it, the stigma around hypospadias will go away completely. The final calling will be when we see these young kids develop into normal citizens and raise their own families and hopefully invite us to attend their weddings.
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January 01 2012

The Usual Questions about Hypospadias by Parents

Nothing is better than actually quoting the questions posed by parents and answering them as I would do in my clinic. So here is a set of questions asked by a very concerned father recently on an email and I have tried my best to answer them using my last few years of experience in working closely for children with Hypospadias.

Dear Dr Singal, This has reference to your consultation at MITR Healthcare Hospital for my son Master XXXXX (6 months old) on xx/xx/xx. My son was diagnosed with Hypospadias soon after birth and was advised for correction surgery. We are basically from xxxx city and I was visiting my in laws at that time and took my son to you for consultation. After consultation you had advised a single stage surgery.

My wife and myself have decided of doing the surgery from you in Navi Mumbai at a hospital which you will advise. As parents it is difficult for us to accept the fact that my son have such problem and at such a tender age he has to undergo surgery, I hope you are able to understand our situation and feeling. As parents I have some queries regarding the surgery.

1. How long will the procedure take?

Answer: The surgery for hypospadias (urethroplasty) can take anywhere between one hour to three hours depending on the severity of hypospadias, associated bend in penis (chordee) and type of surgery performed. In your son’s particular case, since he has a penoscrotal hypospadias my assessment would be that since this is a moderately severe hypospadias, the surgery may take about 3 hours.

2. Will he be given general anesthesia?

Answer: For minor hypospadias surgeries lasting less than 2 hours, we generally give regional anesthesia (caudal epidural block) for pain control/ relief with sedation (so that the child sleeps comfortably throughout the procedure). Hypospadias surgeries needing longer time than that generally require full anesthesia and I guess that will be the situation with your son’s surgery.

3. Will he be 100% cured after the surgery. I mean to say will he be able to stand and pee/urinate like other male child?

Answer: Results of surgery for hypospadias have improved considerably. Please read this blog for more information- http://www.hypospadiasfoundation.com/hypospadias-blog-by-dr-a-k-singal/how-to-prevent-failures-in-hypospadias-surgery-urethroplasty/ buy kamagra online

Currently, more than 90% of the children with penile hypospadias get successful results after single stage surgery and children are able to stand and pee like a normal kid a few days after surgery. In some children, a minor second surgery may be needed if there is a fistula or a stricture.

4. Will his penis look normal like others?

Answer: During hypospadias surgery, we usually take tissue from extra foreskin on top and use the rest of it to provide equal skin cover on all sides to penis. At the end, the penis has a circumcised appearance. Also, if there has been any bend in penis, that is corrected leading to straight penis after surgery. So in nutshell, in most of the cases a few weeks after surgery, penis looks like just that a circumcision has been done.

5. Will the surgery affect his sexual life later on? I mean to say will there be any issue regarding erection, semen ejaculation etc?

Answer: Generally with current surgical techniques preserving nerve and blood supply, the repairs have resulted in very good outcomes both from cosmetic and functional perspective. Some children who have undergone a flap procedure for a severe hypospadias such as for scrotal hypospadias may need an evaluation as the force of semen ejaculation may not be very good. Also a check-up is mandatory later on after puberty at about 13-24 years of age and after 2-3 years of sexual life/ marriage to ensure that the urethra is functioning well.

6. I have gone through internet a little bit and have understood there are few types/methods of the surgery like inverted Y tubularised Plate etc. I would like to know for him what surgery will be undertaken.

Answer: For Hypospadias, more than 100 different types of repairs have been described in last two centuries. Some of these have become outdated with new knowledge. Currently, about 7-8 types of hypospadias repairs are done by hypospadiologists worldwide and these include Tubularised Incised Plate Urethroplasty (Snodgrass Procedure), Onlay flap, Prepucial tube, Glans approximation procedure, Barcat Procedure, two stage urethroplasty- Thiersch duplay type, Modified Koyanagi repair etc. The type of repair is dictated by the type of hypospadias and expertise/ comfort of the surgeon with a particular repair.

7. For how long he will have to be hospitalized and what care should be taken post surgery.

Answer: We generally admit the children in morning and do the surgery in the first half itself. Most of the children are able to go home either in the evening or the next day morning. We try to send them home as soon as possible – more info here: http://www.hypospadiasfoundation.com/hypospadias-blog-by-dr-a-k-singal/evolution-in-hypospadias-management/

Some children who have undergone very complex repairs, or surgery for failed hypospadias or come from outside the city – may need to stay for a longer period of time. The post-operative care includes giving medicine on time, regular double diaper changes and regular follow-ups. The child can take normal diet by evening and can play within the house.

8. How regularly follow ups are required?

Answer: After discharge, we generally call the baby for removal of dressings on day 4-5 and removal of catheter on day 7-10 depending on the type of hypospadias. Sometimes the urine catheter may be kept for 12-14 days in complex hypospadias repairs. Then a further follow-up is needed at 1 month after surgery and then 6 months and 2 years after surgery. Another assessment should ideally b done at 13-14 years of age and later on in adulthood once sexual activity has started.

9. What complications apart from fistula can happen also how soon can we come to know whether a 2nd surgery is required or not?

Answer: Other possible complications after Hypospadias Surgery are

a) Bleeding -Usually rare, minor and stops in 2-3 days.

b) Infection- less common and even if it occurs is usually superficial and resolves with antibiotics

c) Fistula

d) Meatal stenosis: Narrowing of the urinary opening can occur and may need regular calibration or minor cut back called meatotomy in some cases

e) Diverticulum: This may be seen after a flap repair for hypospadias as the skin flap expands and balloons during passage of urine. With careful trimming of the flap during surgery, this has become much less common.

f) Stricture: Sometimes during the healing phase, the new urethral tube may become narrow and require further treatment. This is noticed by poor stream, straining during passage of urine and long time taken to pass urine. This may require further treatment in form of dilatation or a second surgery.

g) Dehiscence/ breakdown: Very rarely, the whole repair may breakdown due to poor healing, infection or loss of blood supply requiring 1-2 more surgeries. This is very uncommon and unfortunate.

We generally get to know about the need for second surgery with respect to fistula by about 1 month after surgery while some other complications like stricture or stenosis or diverticulum may not be apparent till 5-6 months.

Last lines by parents: Please do not misunderstand as we are really very concerned and worried about this and hence we are asking these to you. I look forward for your replies in this aspect. Sorry for asking so many questions.

Answer: Please do not hesitate to ask any questions which you might have. They may sound trivial or silly but please do not have these lurking in your mind. Once we decide to work as a team to get your child better, we should be on the same page and clear all the doubts before surgery. We should also be having the right and identical expectations from the surgery.

Contact Form for Hypospadias Foundation

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Contact Form for Hypospadias Foundation

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Contact Form for Hypospadias Foundation