Pediatric Urologist Archives - Page 3 of 4

November 11 2012

Don’t give up hope on Failed Hypospadias

This is an interesting and inspiring story and I thought I will share it with everyone who has an interest in the field of hypospadias.

About 6 months back, a 14 years old boy was brought all the way from Nasik to my Pediatric Urology clinic at MITR Hospital in kharghar, Navi Mumbai. The parents did not seem to very well educated and were from a farming background. The father was in some class 4 government job. I was wondering why they would travel for 8 hours to a small place like kharghar to see me. Also the age seemed to me a little bit older than the usual age which I see in my clinic. I was intrigued.

The boy seemed little uncomfortable and had furtive glances here and there. Parents and relatives were fidgety too. The consultation began – I asked what brought them to Kharghar. They said that their kid has hypospadias and has undergone 5 surgeries till now but still passes urine from below. I asked them “how did they find me”. They said maternal uncle of the boy knows internet and found me while looking for information about hypospadias. So there it was Internet the great enabler at play.

I went through the case records dating 10 years back. The kid was born with scrotal hypospadias and underwent first major surgery at 2 years of age to straighten the penis (chordee correction) at a top medical college at Mumbai. Post that there were multiple attempts to make a new passage initially using native penile skin and then lining of urinary bladder twice and finally skin graft. Everything had failed and the last surgery was about 5 years back when it was told that there is no hope of the boy having a normal urethral opening at tip of penis. Now I knew the reason of furtive glances and fidgety mannerisms.

On examination, the boy had the urinary opening right near the anus, the penis was still slightly bent (chordee) and there was lots of scarring on underside of penis with deep pits and ragged skin edges. Further there seemed to be a couple of blind passages and left testis also looked higher in position, may be it was caught up in the scar process. Since the opening was even behind the scrotum, the child had to sit in the toilet and pass urine. Overall, the case seemed like mother of all hypospadias.

I counseled the parents and set out a planned staged correction of hypospadias. I told them it will be tough and they will need to be patient and have faith. The plan was to bring him back to his original anatomy first and the reconstruct the entire new urinary passage. As the first stage, I planned to remove all the scarred skin and straighten the penis. In the raw area thus created I was planning to put buccal mucosa graft which is nothing but the inner layer of skin inside the mouth more specifically lips and cheeks. This buccal mucosa graft takes about 3-4 months to heal and then we planned to use this patch to create a new urinary passage. This would give a sure result and the buccal mucosa graft being moist and soft would not have any issues being in touch with urine. Also there would be no hair growth inside the passage in the future.

Well, the parents were convinced because probably I was the first hypospadias surgeon to offer them any hope. So we all set out on our task, an uphill journey.

We took up VW for first stage surgery – expecting about 4 hours of surgical time. But we ended up consuming about 7 hours by doing the following

Cystoscopy and ascertaining usable urethral passage
Excision of all scar tissue on underside of penis
Straightening the penis – chordee correction
Closing the perineal urethrostomy and establishing a penoscrotal meatus.
Correcting the penoscrotal transposition
Left orchioexy was needed as the left testis was caught in the fibrosis
Buccal mucosa graft

But we were satisfied at the end of it all. We could not think of a shortcut as the child had been through a lot. The child remained in the hospital for 7 days and the graft healed very well. At removal of catheter, he was able to pass urine from the penoscrotal meatus without difficulty and was finally able to stand up and pass urine without wetting his pants. I could see the change in his behavior and he seemed more interactive now with me and the hospital staff. We had moved forward by an inch I guess!

4 months later we admitted him again for second stage urethroplasty. The previous graft had healed very well. We could easily make a new urethra just rolling the previous graft plate. This was done over a 12 French silicone catheter without any stress. To ensure full healing we also used a tunica vaginalis graft from the right testis to cover up the suture line.

As I write, the child has finished one month follow-up after urethroplasty surgery and is recovering well from the surgery. He is passing urine currently from the tip meaning the repair is holding well. The final result is yet to be seen and may be another minor procedure may be needed but the journey has been great. Our mood is upbeat and we are sure that we will reach the destination this time or another short journey may be needed 3 months from now. The fact of the matter is that we enjoyed the journey.

It is challenges like these when everyone else has given up, we still gear up and try to do our best for these kids. We may not pass in one attempt but eventually we will. Even if 20% need another surgery that is still acceptable as the final goal can still be achieved.

Contact Form for Hypospadias Foundation

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

October 10 2012

Should a distal hypospadias be repaired!!

I did not know what was in store for me – there was 6 new patients in clinic and only 4 follow-ups and by the nature of it new patients take more time and follow-ups finish very fast. Anyway, the first patient who walked in was a 3 year old accompanied by young smart looking parents. The boy flashed a big smile and I said hello and he was eager to shake hands. That was a positive sign – Acceptance of me as a friend. Good so far.It was a nice Saturday evening, the watch clicked 7pm and I was in my Pediatric Urology clinic at Vashi with the last 10 urology appointments and was slated to be back home by 8pm.

Invariably on Saturdays I get late but today I was all energized to finish consultations fast and head back home for a quiet dinner and then catch up on much neglected sleep.

Then we got down to the business of consultation- the parents had looked up about hypospadias on internet and had found me and then travelled all the way to Navi Mumbai on a Saturday evening for a consultation for their little one who had hypospadias. I examined the eager and cooperative kid- he has a coronal hypospadias with mild tilt of glans (the head of penis). There was no chordee (actual bend of the body of penis) and testes were in normal location. Overall, it looked like a milder distal hypospadias which should be fairly easy to repair with a predictably good result.

I explained everything about hypospadias – how it happens and how it is repaired and then the QA began. The parents asked – “Is it necessary to repair it? We have heard that it can lead to long term urinary problems and sexual dysfunctions as sometimes the nerves get cut during sensation leading to a numb penis. Also, there are blogs which talk about no need to do surgery in distal hypospadias as there may be long term complications like hair growth, tight passage, fistulas etc.” They had visited an eminent Urologist who had advised against surgery.

Well, they had done their due research and it was good but sometimes the truth out there may not be whole truth. I had to counsel them and make sure that they know the whole truth while at the same time sounding detached from the whole process. It was after all their kid and their responsibility- my job was to give full, fair and medically sound information and then their job was to make the right decision for their kid.

So here are the facts as I discussed with them:

As the boy grows and finally the penis size become adult like, the deformity becomes more and more obvious. The glans (penis head) which was tilted will look more and more abnormal.
The prepuce will only be on the top of the head and not on the underside leading to an incomplete prepuce. It looks rather like the head of a cobra in adulthood
The urinary opening will be on the underside of penis and the urine stream will always be downward instead of forward as in a normal child.
The problems as stated above will be more cosmetic than functional but they affect the psyche as he will be able to see that the shape and configuration of his penis is quite different from that of other children. This can lead to deep seated emotional and social withdrawal issues in teenage and adulthood.
Repairs are easier with predictable and better results in childhood. Later on in teenage and adulthood repairs have higher failure rates and pain. Further erections can cause pain and instability in the repaired area after surgery.
The blogs out there contain stories of people who underwent surgery for hypospadias in childhood and now are adults. Thus the care which they received was 20-25 years back. The art & science of Hypospadiology has moved at much faster pace in last two decades and now- the understanding of anatomy of penis & hypospadias is much better, the surgical techniques have evolved and most of the repairs are done in single stage, new instruments for finer surgeries are available, new fine absorbable & non-reactive stitches are available and above all there are doctors who are well trained in managing the children with hypospadias.
Earlier surgeries using skin from scrotum or other body tissues are not done any more so currently any repair causing hair growth in urethra is outdated and not done by surgeons.
Complications like fistula, tight passage (stricture) are less than 5% in experienced, trained surgeons hands for milder distal hypospadias.

To sum up, it is worthwhile to repair distal hypospadias considering all the above. The science of hypospadias surgery has made sure that the children get the best results for surgery in their early childhood and then live their lives normal without worrying about their reproductive organs.

Contact Form for Hypospadias Foundation

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

September 09 2012

Recovery after Hypospadias Surgery (Urethroplasty)

One of the common questions which the parents ask in clinic when I counsel them for hypospadias surgery is “how many days will it take for my kid to recover after hypospadias repair/ surgery”

And my answer though very detailed, could be read two ways

One I am avoiding a straightforward answer and the second may be that I want to give a deeper and more enriching answer which clears all the doubts and answers the question in its whole entirety

The recovery can be of many types.

The immediate and the most concerning is the Recovery from anesthesia and this usually within 2-3 hours after surgery implying that the kid will be able to talk, converse and start taking liquids etc after surgery. Usually after 6-8 hour of surgery kids can take solids and normal diet. We have made sure that our operation theatre and the surgical team is baby friendly to make sure that the recovery is fast and kids go home fast. The anesthesia used is caudal plus sedation in most cases, there is a warming mat under the baby during surgery to prevent low body temperature, the anesthesia team is trained in managing small babies, and all the equipment for anesthesia and surgery is baby friendly. Above all the hospital staff at MITR makes suresthat the child is well cared for and parents are made comfortable during the stay.

Recovery to playing and walking etc usually happens by evening and often I find kids fully comfortable and running around by the morning of day after surgery. That’s also the reason why we moved from bulky dressings and bags- avoiding these and using a double diaper method of managing kids after surgery allows them full freedom of movement.

Recovery from dressings & catheter takes more time. After hypospadias surgery, usually after hypospadias surgery at 4-5 days and catheter after 7-10 days, depending upon the complexity of hypospadias repair. In some distal hypospadias we remove the dressings and catheter at the same time which is at first follow up one week of surgery. This saves unnecessary visits to the hospital. Over all intent is to make hospital visits for the kids as less as possible.

Recovery to a new urethra in the larger sense of passing urine through the new passage happens when the child starts passing urine comfortably which can be expected 2-3 days after removal of the catheter. For the first two or three days there may be little bit of pain in passing urine through the newly formed urethra.

The final recovery happens when the swelling of the penis subsides, the sutures get absorbed and the penis assumes its final shape and thus one can see the cosmetic outcome. This time which the swelling takes to go away may be variable but usually takes up to a month after hypospadias surgery.

Penis is an organ which has a tendency to swell up at the slightest excuse be it a minor infection, injury and this happens quite significantly after hypospadias surgery. Equally importantly the penis is also an organ which heals very fast and almost normal skin cover comes back even after an extensive repair which a lot of penile skin gets rearranged during surgery. Sometimes the penile skin looks very raw and incomplete for some days after surgery but when the patients finally come back after a month it looks like no surgery was done as the skin of penis has an amazing regenerative capacity. Partly this is because of an extensive blood supply of penis skin and partly because of the loose specialized skin.

Especially in kids after hypospadias surgery or urethroplasty, sometimes the penis looks black, blue, swollen and bruised and yet after a month or so everything looks so normal as if just a circumcision has been done.

We have started using specialized Tegaderm and light gauze dressings as these do not impair the blood supply by putting the pressure on already swollen penis after hypospadias surgery. Also, a loose dressing decreases pain and allows tissues to breathe.

Tegaderm is a transparent cling wrap kind of dressing which is very easy to take off and gauze piece is made of soft cotton which is rolled around penis for 3-4 turns and then held with a micropore tape. One more throw of the tape also helps in holding the catheter in place after surgery. These tapes are fairly easy to take off in outpatient clinic mostly by junior staff. Catheter is held by a small fine stitch to the glans and this can b easily cut in outpatient clinic to remove the catheter.

Contact Form for Hypospadias Foundation

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

September 09 2012

My child is very naughty!! How will I manage him after surgery!! – Putting on the parents cap

Understanding postoperative problems after Hypospadias Surgery (Urethroplasty) in children

This is the second most common question asked by the parents when I counsel them for surgery for hypospadias!

After Hypospadias Surgery (urethroplasty), this is often the most important management issue for the parents – though more for the mother than for the father. We as clinicians may often focus more around the medical issues – the pre-operative checklist, the steps and arrangements for hypospadias surgery, the stitches, antibiotics, anesthesia and dressings. But what about the rest of the issues – what about the child himself, the issues which parents face may face 24/7 like pain, food, tantrums, diaper changes, naughtiness management etc. I guess it is time that we doctors should see 360 degrees around whatever goes in treating a child with hypospadias. We should attempt to cross the line to the other side and think like a parent and then should be open to discuss all these questions and answer them placing ourselves in parent’s shoes.

So here are the facts as we see them:

Pain: The main concern after surgery is often the pain. Since penis is very sensitive organ with intricate nerve supply, sometimes there may be significant pain for the first 3-4 days. But pain is also a variable symptom as intensity may vary from one child to another. Sometimes children who have undergone severe hypospadias repairs lasting 3-4 hours do not complain of pain at all and are running around pain free the next day while some children with a minor hypospadias repair may complain of a lot of pain. We usually prescribe enough pain killers and antispasmodics to care of pain as well as bladder spasms but still the kids may be a bit irritable for the first couple of days.
Diet & feeding: We generally allow children liquid feeds 3-4 hours after surgery and then gradually advance to a full diet by evening itself. Sometimes the children may be a bit sleepy and fussy for a few hours after surgery but eventually most of the kids are on full normal regular diet by the evening of hypospadias surgery.
Diaper care: Children are kept in a Double Diaper Care Program after surgery to avoid catheters hanging with a bag. A small hole is cut out into the front side of the inside diaper and the urinary catheter is taken out through this to drain into the outer diaper. The inner diaper thus needs to be changed whenever the child passes stools or twice a day atleast and outer diaper whenever it gets wet with urine. Double diaper care allows the child to move around, walk or play without the bag hanging to his waist or leg. Also, the chances of a catheter getting accidentally pulled out are much less when it is draining within the diaper.
Medicines: There are about 4-5 medicines in liquid syrup form which are administered to the baby after hypospadias surgery. These are an antibiotic, a pain killer, an antispasmodic and a medicine to prevent side effects (acidity) due to pain killers. In bigger children, we also prescribe diazepam to prevent painful erections. Medicines are usually given for 7-10 days after surgery.
Catheter care: Catheter is a plastic tube which is placed into the bladder and thus supports the new urethra. Catheter drains the urine continuously into the diaper and allows the stitches to be dry during the critical phase. The catheter is kept for a period ranging from 5 days to 12 days depending on the type & complexity of repair.
Dressing issues: At the end of hypospadias surgery a soft gauze dressing is applied on the penis and this is generally removed after 5-6 days of surgery. Sometimes there may be a small amount of blood staining after surgery or dressing may slip off after 2-3 days but this will not affect the outcome at all. After dressing is removed, the penis may look swollen and reddish as penis is an organ which swells frequently after surgery. The swelling goes away on its own in 1-2 weeks time and raw areas also heal up very fast.
Minor bleeds: Penis being a very vascular organ has a very rich blood supply. There may be a minor bleed from the head of the penis in the first 2-3 days after hypospadias surgery. This generally presents a spotting on the diaper or the dressing.
Cosmetic outcome: The final cosmetic aim of hypospadias surgery is to give a circumcised appearance with an absolutely straight penis. The meatus should be at tip with a slit like normal appearance. The final cosmetic outcomes will take about a month after surgery to be seen.
Cleaning and bathing: Children are not allowed formal full body bath for a first 4-5 days after surgery till the time the dressing is in place. Sponging can be done taking care not to wet the dressing. Once the dressing has been removed it is advisable to give warm tub baths twice a day for the next two weeks. This allows the warm water to wash away all the clots and debris and swelling also reduces. After bathing, the penis should not be dried while rest of the body can be dab dried. Ointment is applied and then the diapers can be placed.
Follow-ups: Follow up is done day 5-6 after Hypospadias surgery and then at catheter removal, one week, one month and 3 months later. Healing, caliber of the new urethra is assessed at every follow-up. This may include a gentle calibration with a catheter by the doctor in the clinic itself.
Naughtiness management after hypospadias surgery: This is the most difficult question to answer as there is no single answer to this issue. To me all the kids are naughty and all of them manage fairly well after surgery. I haven’t heard too many parents cribbing after surgery that they had an issue with managing the kids. There are so many ways to keep the kid happy after surgery like toys, books, video games or just being around.

Contact Form for Hypospadias Foundation

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

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Tag Archives: Pediatric Urologist

Contact Form for Hypospadias Foundation

Contact Form for Hypospadias Foundation

Contact Form for Hypospadias Foundation

Contact Form for Hypospadias Foundation