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May 05 2014

Complications after Hypospadias Repair Surgery in children

Hypospadias repair surgery is a very delicate and demanding surgery. It tests the ingenuity of the hypospadias surgeon, surgery skills and most importantly experience. We have realized that hypospadias repair procedure is not a surgery which can be done casually or as one of the many surgeries which a surgeon does. Best results of hypospadias surgeries are seen only when the surgeon dedicates his time and energy in pursuing the art and science of hypospadiology. Results keep on improving day by day and year by year. With more than 600 hypospadias repairs done over last 5 years, Hypospadias Foundation at MITR Hospital, Navi Mumbai, India provides the best results in hypospadias surgeries in south East asia. Children have travelled from all over India and other countries such as Nigeria, Greece, Bangladesh, Iraq, UAE to get treated under Dr Singal’s care for hypospadias.

To get the best outcome in hypospadias, it requires a big team effort which includes hypospadias surgeon, assistants, well trained OT staff and post-surgery caring staff.

No surgery is free of complication and complications happen even in the best of hypospadias surgeon’s hands though they keep in decreasing with advancing experience. Whenever we see any child with hypospadias in our clinic, we make sure that we discuss in detail about the possibility of complications and the post hypospadias surgery outcomes. Some of these we discuss it further here:

Immediate complications after hypospadias repair:

Bleeding – Penis is a very vascular organ with a lot of blood supply. Since hypospadias surgery involves lot of dissection of penis and making of various flaps, suturing them back in proper way is very vital in preventing this complication. The bleeding is usually minor and stops in 2-3 days. Earlier we used to apply heavy and tight dressings after hypospadias surgery but now we have realized that these actually delay healing as they compress the healing tissue. So presently the dressings which we use are very soft and light.
Infection- After any surgery, the immunity of the body goes down plus there is raw area which invites growth of infection causing bacteria. Fortunately, when we do hypospadias repair in children, infection is very rare and even if it occurs is usually superficial and resolves with antibiotics. Various preventive actions are taken before hypospadias repair such as very sterile techniques in operation theatre, broad spectrum antibiotic at start of surgery and 8 hours after surgery, oral antibiotics after surgery and careful handling post-surgery.

Short term complications after hypospadias repair:

Urethral Fistula: Fistula implies leakage of urine somewhere from the newly formed urethral tube below the tip of penis. This occurs because of improper healing resulting from poor blood supply, infection, tight stitches or just poor surgical technique. Sometimes the urethral fistula after hypospadias surgery may heal by itself but mostly it requires surgery which is recommended only after 6 months of first hypospadias surgery. Fistula occurrence depends on experience of the hypospadias surgeon, severity of hypospadias and technique.
Meatal stenosis: This refers to a tight urinary opening after surgery of hypospadias. This can be seen even 2 weeks after surgery and may need regular calibration or minor cut back procedure called meatotomy in some cases.
Diverticulum: This refers to formation of a baggy distended urethral tube and is visible during passage of urine. This may be seen after an onlay 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 and occurs in less than 1% of cases after hypospadias surgery.
Stricture: Sometimes during the healing phase, the new urethral tube may become narrow and cause obstruction to urine flow. This is noticed by poor stream, straining (application of force) during passage of urine and long time taken to pass urine. This may require further treatment in form of dilatation or a second surgery some months later.
Dehiscence/ breakdown: Very rarely, the whole repair may breakdown due to poor healing, infection or loss of blood supply requiring more surgeries. This is very uncommon and unfortunate event necessitating a complete redo repair of the hypospadias.

With the newer techniques of hypospadias repair and growing experience of hypospadias surgeons, the complications have become much less common after hypospadias surgery and even when they occur they can be managed well. It is well said that “the prepared mind never knows much trouble”. Once we know that complications can occur in any surgery and be prepared for them, it is much easier to initiate preventive action during surgery itself. Also, it is vital to identify complications earlier so that they can be managed well in time before any long term damage occurs.

About the author:

Dr A.K.Singal is a Pediatric urologist and is renowned as one of the best hypospadias surgeons in India for his dedication towards Hypospadias and excellent results of hypospadias surgery. He has been an invited speaker in various national and international medical conferences and workshops for hypospadias. He is also the founder of Hypospadias Foundation – an organization dedicated to best of care for children with hypospadias. Dr Singal practices art and science of hypospadias treatment in Mumbai and Navi Mumbai area of western India.

Visit Hypospadias Channel https://www.youtube.com/user/pedurohypospadias

Watch videos of Hypospadias surgery by Dr A.K.Singal

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

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

Contact Form for Hypospadias Foundation

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

April 04 2014

Letter from Across the seas : Mother of twins shares Hypospadias Surgery guide for parents

Letter from Across the Seas:

Dear Dr Singal,

Trust all is well with you. We are glad that we came all the way to India to you for our boys and are thankful to you for treating our boys with such care and in a single stage surgery for Hypospadias. As discussed, I have written the write up for the blog. These are basically my views, learnings and tips for other parents, especially the Hospitalization including pre-surgery and post hypospadias surgery course.

Regards,

S.P.

Dubai

THE WRITE-UP

———————–

Dear Parent,

As parents we all are concerned for our child(ren)’s wellbeing. We interact a lot with Pediatricians and Specialist Pediatrician from birth till their teens. From Vaccinations to Major surgery we ensure our child(ren) gets best of the treatment and care. Until both my twin boys were detected with Hypospadias, I was inexperienced and the entire journey from initial diagnose to surgery has taught me a lot.

Here are some tips, learnings and guidance for parents

Before the meeting the Doctor

1. Most cases of Hypospadias are detected at birth. The Pediatrician at birth may not be expert enough to guide further so it’s better to consult a Pediatric Urologist or expert hypospadias surgeon as soon as possible.

2. There is no benchmark for earlier consultation, but its better the visit to the Pediatric Urologist when the child is less than 6 months old.

3. If you are an outstation patient and are communicating with the doctor over emails ensure you share following info:

Baby’s Allergies and medications
Any special medication or condition
Any hospitalization and the reason

Sometimes this information doesn’t affect the course of hypospadias surgery but its always safe to share as this helps the anesthesiologist for planning a safe anesthesia

4. If you have a limited timeframe for your visit than

Check if there are any further tests (like blood or urine tests) or investigations required before you meet the pediatric urologist
As required by the doctor, perform the tests and send the reports to doctor for further guidance. This can be done via email. Since I was traveling from Dubai, I did these tests as recommended by Dr Singal even before I landed up in Mumbai
Sometimes a certain blood count such a hemoglobin may be needed to be normal before hypospadias repair procedure is required to perform before surgery and if the count is not as preferred it may take month to reach the desired level.

5. Check for the travel plans of the doctor so that it doesn’t clash with your visit. Sometimes the doctor maybe traveling for vacation or for a conference.

6. Convey your travel plans to the doctor

Once you meet the doctor, most of your doubts will be cleared in the initial meeting. A date for hypospadias surgery will be decided in the meeting. If you have questions or doubts regarding the hypospadias treatment procedure please ask the doctor, he will be happy to guide. Sometimes you may have doubts or questions post consultation check with the doctor if you can email for such doubts. The doctor may suggest hospitalization before the day of the surgery and also some additional tests whenever needed.

My twin son’s both had hypospadias and we elected to have surgery for first kid on Monday and second one on Tuesday.

When we reached the hospital we had some minor issues as it was Sunday and we were supposed to see the doctor on call in ER. Since they were already alerted for our visit the doctor on call was prepared with all the requirements. They were to do a blood test on one of my twin. To avoid double prick they decided to insert cannula for one of my boys. And then the hell broke. We had two crying babies (one due to prick and other seeing the first one) and there were hospital formalities to be fulfilled.

Hospitalization

1. Before admission to the hospital

Reach hospital half an hour before the schedule time.
Insist – The Cannula And Blood Tests Be Done Only After The Kid Is Settled In The Room
Request for the allotment of room and fulfill all the formalities
Ask for hospital clothes for the baby
Change the baby in hospital clothes
Once the child is settled than ask doctor on call to the needful

2. Inform the hospital staff if your child is on a special diet and if they can provide.

3. Carry baby products – wipes, diapers, any special food or milk powder you may be giving, soft toys which soothes them

4. Carry you basic requirements for two days of hospitalization

5. Since the hypospadias operation will be done under anesthesia, check till when the child be given food/water/milk.

After Care

1. Learn to change the baby double diaper. We were happy as with double diaper technique the babies were nicely tugged in and there was little fear of catheter dislodgement.

2. Learn the medications of the baby

3. Don’t discontinue medication unless the doctor advise

4. Follow up visits with the doctor

The child will have discomfort and can be cranky due to operation the doctor will guide you. This is a normal phase after any surgery with children as penis is a sensitive organ and pain may be there for a first few days. But as one learned person said “ This too shall pass” It did pass for us. Now when we look back, the difficult days just went by in a jiffy. With the love and support of Dr A.K.Singal, junior doctors and nurses, we saw them through.

My personal advice – Stay Calm and positive through the process.

All the best

Regards,

An experienced Parent

——————————————————————-

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

Contact Form for Hypospadias Foundation

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

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

Contact Form for Hypospadias Foundation

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

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.

Contact Form for Hypospadias Foundation

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

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Contact Form for Hypospadias Foundation

Contact Form for Hypospadias Foundation

Contact Form for Hypospadias Foundation

Contact Form for Hypospadias Foundation