Hypospadias Archives - Page 2 of 5 - Hypospadias Foundation

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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January 01 2014

Living with Hypospadias- Adults with hypospadias

The tale of hypospadias does not stop in first few years of life for everyone. This is especially true of adults and adolescents who underwent hypospadias surgery repair using older techniques and with lesser trained Hypospadias surgeons 15-20 years back. While a majority of these have done well, there is a sizable population of adults in India who have persistent issues secondary to hypospadias such as urethral fistulas, persistent penile chordee (bending of penis), urethral stricture or bad cosmetic outcome. As Pediatric urologist and a surgeon with deep interest in hypospadias (hypospadiologist), we keep seeing such patients on a regular basis now.

There are atleast estimated 5 lakh adults/ adolescents in India with untreated, complicated or residual issues of hypospadias in India. Some of these people live an unsatisfied life thinking that no cure is possible because that is what they have been brought up to think. Individuals who have failed multiple surgeries are called Hypospadias cripples in medical community signifying the crippling effect which inadequately treated hypospadias can have in a person’s life.

Fortunately, with newer techniques, better hypospadias surgery instruments, very good sutures like PDS, availability of dedicated hypospadias surgery teams and expert hypospadias surgeons good results are possible in any patient with previous failed hypospadias surgery even in hypospadias cripples.

Here is story in point:

Six months back I saw Mr RK, a 30 year old young man, who had been a case of failed hypospadias – operated for hypospadias twice in his childhood in a hospital in Delhi. Both the surgeries had met with partial success and his parents had left him like that and lost hope at a completely functional urethra. RK had been a good student and went on to do Engineering graduation from IIT and then a MBA from Pune. He had taken up a job in multinational company and now was planning to get married. Infact, he had delayed marriage inspite of a successful career because he was never satisfied with outcome of his hypospadias surgery. That’s why he looked up on internet and came to see us at Hypospadias Foundation in Navi Mumbai.

At the first consultation itself and being in relatively the same age group, we hit it off really well and he was quite frank and objective about his condition and that kind of interaction helps a hypospadias specialist like me. When I examined him, he had a persistent mild chordee but the bigger issue was his urinary opening (meatus) was not on the tip of penis (glans penis) but way down in distal penile location. He had many skin bridges and scarred islands of skin and a large urethral fistula in proximal penile region. There was a bit of penoscrotal transposition as well. On questioning, he was passing 50% of the urine from the urethral fistula and 50% from the distal penile location without any straining and in good urinary stream. None of these problems were major by themselves and could have been cured easily but after two failed hypospadias repairs in childhood, I think parents just gave up hope.

So we discussed with RK at length about the various things which needed to be done-

Distal urethroplasty using flap from nearby ventral penile skin,
Closure of urethral fistula (fistula repair) in multiple layers with tunica vaginalis flap
Correction of penoscrotal transposition
And chordee correction by dorsal plication.

The surgery was done next week at MITR Hospital & Hypospadias Foundation. Dr Manish Dubey, Urologist and Co-founder of Hypospadias Foundation helped me with the surgery and management immediately post surgery. RK was sent home the day after surgery. A follow up visit for hypospadias dressing removal was planned on day 5 and catheter removal o day 10.

Some of things especially in adults undergoing hypospadias surgery, which we took care of to ensure smooth recovery and are different from children:

Postoperative pain and erections
Choosing the right urethral catheter and drainage bag

We were also worried about higher chances of wound infection and bleeding after redo-hypospadias repair. For pain and prevention of erections we gave benzodiazepine derivative tablets and phenobarbitone along with diclofenac and that helped pretty well for two weeks. For the catheter, we used a Foleys silicon catheter for 10 days and left it to drain in a urine bag which RK could carry with him and walk around within his home.

Fortunately, everything went well and now after 3 months of hypospadias surgery, the hypospadias surgery site is healing well and there is no more pain during erections. The urine stream is good and RK is passing from the tip of his penis for the first time in his life standing like a normal man. He is not shy to use the public toilets anymore- He just stands up and delivers.

We have asked him to wait for three more months before planning marriage and these three months he is actually going to spend in finding the right girl for himself. For him, we hope the chapter of HYPOSPADIAS is closed now.

The only question remains whether as a Hypospadiologist I will get invited to his marriage- if yes, how will he introduce me? As the doctor who fixed his penis? I think that is too much and I will just skip attending his marriage and I wish him the best of luck always from our side and from everyone at MITR hospital and Hypospadias Foundation in Navi Mumbai, India.

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October 10 2013

Hypospadias Surgery In India

Every year more than 100,000 (1 lakh) boys are born with hypospadias in India. It is s staggering number.

This incidence has been calculated from birth rate for male babies according to Census 2011 and considering that the worldwide accepted incidence of hypospadias is around 1/150 male births. Further we have adjusted this for infant mortality rate. Though our own research in a population study done by Hypospadias Foundation in Vashi & Nerul areas of Navi Mumbai has shown an incidence of hypospadias around 1/126 male births, the base population was only 1200 births which was not very big, hence we did not use this figure.

At Hypospadias Foundation, we are concerned about this increasing incidence of hypospadias across the globe and we are planning to devote time and resources towards research. At the same time, even if we ignore minor hypospadias and those babies without chordee, in whom we can avoid surgery, still about 70,000-80,000 babies will need hypospadias repair surgeries in India every year.

In India, hypospadias repair surgeries are performed by pediatric urologists (wherever available), pediatric surgeons, urologists as well as some plastic surgeons. Some of these surgeons have learnt the art of hypospadias surgery with a formal pediatric urology training while others have gained experience due to their personal interest and have achieved good results. Fortunately, there are short team visiting courses available at some international centres and also with the availability of good learning resources on internet, surgeon with special interests in hypospadias can explore multiple avenues for training. Infact the current generation of hypospadias surgeons is learning quickly and also starting their careers at a better knowledge base than surgeons who were learning hypospadias two decades back. Newer instruments, newer surgery techniques and sutures have improved the hypospadias repair outcomes.

At centres like Hypospadias Foundation at MITR Hospital, Navi Mumbai, India – a team of two surgeons with special interest in Hypospadias – Pediatric Urologist & Hypospadiologist- Dr A.K.Singal and adult urologist – Dr Manish Dubey- work together to enhance the outcomes of surgery both in in children as well as adults with hypospadias. While the aim of the team is to spread awareness and also provide for early surgery in infancy for children with hypospadias, they are also reaching out gradually to many older children and adults with failed hypospadias repairs, persisting or residual hypospadias issues. At Hypospadias Foundation, almost every week, the team gets to see an adolescent or an adult with persistent hypospadias issues such as chordee, urethral fistula, urethral stricture, or poor cosmetic outcome such as buried penis. Some of these patients have multiple problems either due to partly or improperly repaired hypospadias in childhood. These cases are looked after by the team with special attention and effort. You can see such a cases:

14 years old Multiple failed hypospadias surgeries in childhood

With growing team and experience, the number of children and adults undergoing hypospadias surgery at Hypospadias foundation have steadily increased over the last five years. This year in 2013, we will finish with around 150 hypospadias surgeries and though it is good but it not even 1% of the total burden in India. We hope to start training pediatric surgeons and urologists so that within India there is facility for budding surgeons to learn the state of art hypospadias surgery.

Healthcare and specifically surgery is all about trust and for complicated diseases like hypospadias it takes time to achieve trust. Every single child who has undergone a successful surgery at Hypospadias Foundation, the family has spread the goodwill and good word about the dedication of our team. In the last two years, we have been lucky to be a part of treatment process and lives of lot of outstation and international patients – some have come in from Surat, Jalgaon, Nasik, Kolhapur while others have travelled even from Delhi, Ahmedabad, Bangalore, Jaipur and even as far as Jammu or Calcutta. Internationally, we now offer assistance to 1-2 patients every month from countries like Sri lanka, Bangladesh, Pakistan, Nigeria, Kenya, UAE and Congo. Most of the patients who travel these large distances are either failed hypospadias or complex hypospadias who haven’t been able to get satisfactory counseling or answer to their problems.

Our team at Hypospadias Foundation helps the families with email guidance, online consults, follow-ups and planning travel and surgeries according to availability of Dr Singal and Dr Dubey.

You can watch Videos of Hypospadias Surgery on our youtube channel:

Hypospadias Channel

Videos:

Distal penile hypospadias repair

Severe Hypospadias single stage repair by Dr Singal

Contact Hypospadias Foundation

Dr A.K.Singal can be contacted at

MITR Hospital & Hypospadias Foundation, Kharghar – 022-27742558/ 4229 & 9324180553

Mon/ Wed/ Fri 5:00-6:00pm

MGM Hospital Vashi – 02261526666, 6607

Mon/ Wed/ Fri 7:00-8:00pm

MITR Clinic, Vashi- 02265163816, 9324502572

Tue/ Saturday 7:00-8:00pm

Fortis Hospital, Sector-9, Vashi- 02239199222, 200

Tue/ Saturday 6:00-7:00pm

Watch our youtube channel for videos of Hypospadias surgery – Pediatric Urology & Hypospadias Channel

You can write to us at dr Singal’s email Id – arbinders@gmail.com for a second opinion or guidance.

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July 07 2013

Twin babies with Hypospadias- Dilemmas in management!

Last Monday was like any other Monday. My pediatric urology clinic was full with appointments and I was getting into the rhythm of seeing children with complicated urinary problems and hypospadias. A young couple walked in with twin male babies, each about 7 months old. The boys were naughty and attentive and soon were soaking in the yellow and pink and greens of my outpatient clinic. I looked at the file and asked them the pediatric urological issues for which they were seeing me that day. They said their kid had hypospadias and both of them had hypospadias infact and they wanted to see a Pediatric urologist. Now that was a shocker!! Though this was not the first time that I was seeing twin boys with Hypospadias, but it was that once in two years phenomenon. And more striking since these boys had exactly the same type of hypospadias- which was distal penile hypospadias with mild chordee. Last year I had treated two brothers with hypospadias but the age was 3 and 5 years and thus difference in age was 2 years. The elder one has a mid penile hypospadias while the younger one had a distal penile hypospadias. I suddenly remembered the dilemmas which face a Pediatric Urologist & a Hypospadiologist while treating siblings with hypospadias.

• Which boy do you treat first – plan according to age – elder first or severity wise and severe hypospadias first and minor later?

• Whether you do them the same day or one after the other or with some gap of days in between?

• How will the parents manage two babies getting operated for the same thing at the same time?

• And if you operate one baby with hypospadias first and second one a few days later- what is the effect on their minds? How do they cope up with a situation where one has undergone a hypospadias surgery and the other one is waiting. Does the second kid get scared seeing the first one in pain after surgery and undergoing hospital visits and checkups? It was a tough situation to be in – for me as a hypospadias surgeon and even more for the parents who will have to care for the children 24×7 after surgery.

After a lot of deliberation, we decided that we do the hypospadias repair one after the other but on the consecutive days at MITR Hospital & Hypospadias Foundation. We admitted the elder sibling (with more severe hypospadias) for surgery on Tuesday morning and surgery was conducted as the first case in the morning. The younger kid was admitted on Wednesday morning and underwent uneventful repair on Wednesday itself. We arranged for two beds in one room so that both of them can share their side of the story. At least here there was no scope of having a feeling of being left out. Both of them for a fact got a HYPOSPADIAS SURGERY. Recovery period after surgery was smooth and both of them were discharged on Wednesday evening. The kids came back for follow-up on the same day after a week and their catheters were removed the same day. The children pee’d and actually compared their streams and for me luckily- both had good thick straight urine streams without any complications. Deep inside, throughout the recovery period, I was a bit worried about a complication happening. Luckily, everything went well and I had two happy kids with me. Now coming back to present case at hand- where I have a set of twin babies with hypospadias. So going by my previous experience, I think we will stick to the same plan. The only advantage here is that the kids are still less than one year of age and they won’t think much about surgery. I am planning to do them on a Tuesday and a Wednesday and then send them home on Wednesday itself.

Medicine lends itself to unusual off the script events every day and as we say every patient has a story. For us at Hypospadias Foundation – we believe every child hypospadias has a story with happy ending.

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Contact Form for Hypospadias Foundation

Contact Form for Hypospadias Foundation

Contact Form for Hypospadias Foundation

Contact Form for Hypospadias Foundation