redo hypospadias repair Archives - Hypospadias Foundation

January 01 2020

Dr A.K.Singal presents his work at Hypospadias World Congress at Childrens Hospital of Philadelphia, USA

Hypospadias Foundation starts Clinic for Hypospadias Treatment & Surgery in Bahrain

Dr A.K.Singal was an invited speaker at Hypospadias World Congress at Children’s Research Center at Children’s Hospital of Philadelphia, USA, held between 30^th October 2019-1^st Nov 2019. Dr Singal presented four papers on hypospadias treatment and moderated scientific sessions during the conference.

The conference saw participation from more than 150 pediatric urologists and hypospadias specialists from across the world. The conference solely focussed on hypospadias. Various aspects of hypospadias were discussed such as etiology, diagnosis, hormonal tests and supplementation (testosterone injections), surgery techniques and complications/ results of hypospadias surgeries.

Dr A.K.Singal

Dr Singal with Dr Long & Dr Zaontz

Dr Singal presented the following lectures and papers in the World Congress:

Buccal inlay graft for failed hypospadias- Dr Singal showed technique of buccal (oral) mucosa graft inlay surgery and its results in failed hypospadias cases.
Considerations in adult hypospadias repairs- Adult hypospadias are difficult to manage especially if the surgery done in childhood has failed. Dr Singal showed innovative surgery techniques for such adult hypospadias cases for best outcomes.
Reimagined Byar’s flaps for staged hypospadias repairs- For hypospadias with severe chordee, it is important that the penile curvature gets fully corrected in first stage and then second stage surgery is done for bringing the urethra to the tip of penis. In expert hands the results of two stage surgery for hypospadias with severe chordee is very good. Dr Singal showed finer nuances of surgery to achieve best results to the audience.
Parental Awareness survey for families with hypospadias: Families of children or adults with hypospadias are often not fully aware of the extent of disease and what it means in the long run. Dr Singal and his team conducted a study of 150 families to understand about their concerns about hypospadias and their knowledge level about the disease/ surgery.

Overall the three-day conference resulted in great mutual exchange of ideas and also helped younger generation of surgeons learn from eminent faculty from all over the world.

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.

Contact Form for Hypospadias Foundation

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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

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September 09 2012

Hypospadias in Adults- Setting the right goals and expectations

I get a lot of enquiries about hypospadias through our Hypospadias foundation website – Most of these are from concerned parents, sometimes from relatives, sometimes from referring doctors but rarely from patients themselves. For writing about themselves, the patients have to be old enough to go on Internet and seek help. And with advancing awareness, these days most of the kids are referred to me in first few months of age and sometimes even in newborn age. So to get an inquiry from a patient happens only a couple of times in a month. And most of these are enquiries before an impending marriage!

I was intrigued when I got an email from a VK 34 years old man wanting to consult me for hypospadias. My assistant, Akshay, explained to him about my consultation time at MGM vashi and at Mitr hospital.

On Monday evening, VK wrote to me again saying that he went to MGM Vashi but they refused to make a file for him and sent him back with the explanation that Dr Singal treats only kids till 15 years of age. I felt really bad and I sent an email back to him and asked Akshay to schedule an out of turn consultation for the young man on Tuesday. Tuesday otherwise is usually my free day.

So Tuesday evening, in walked VK, a smart confident young man. He was working as a senior software analyst in a well known consulting company and was married for last 3 years. The consultation began on a nice note. I went through all the papers dating back to one year of age. VK was born with a scrotal hypospadias and had undergone two stage repair at Wadia Hospital when he was 5 years of age, thereafter he had required a couple of minor procedures for narrowing of passage and urethral fistula but was mostly passing urine well. His main reason for consultation at this time was infertility. Secondary issue which we discussed was splaying of urine at time of passing urine. His urine came out in a form a spray rather than a well directed stream and he would often wet his pants and thus found it difficult to use a urinal for expeditious passing of urine.

His sperm count was almost normal and he was able to have normal erections and ejaculations. The ejaculate was not forceful so an intrauterine insemination (IUI) had been tried but two sessions had failed.

His secondary problem of a sprayed kind of urine stream was due to a wide open urinary meatus (hole) with a funnel kind of appearance and lot of loose skin folds around it. Also, the urinary opening was not at the tip of the penis but was rather on the underside about 3 cm from the tip.

From a functional point of view, the location of the urinary opening was not in too bad a location to cause infertility. Also, since IUI had failed, I was sure that the infertility problem was not due to hypospadias per se. Given the high incidence of primary infertility these days and advanced age of the mother (34 years), the infertility may have been because of some other factors.

In his own mind, VK had thought that it was his hypospadias problem which was causing infertility. I spent close to 40 minutes trying to draw diagrams and explaining to him that we should look for other causes of infertility. Finally, he was convinced and then I referred him to an infertility specialist and an andrologist. The plan was:

Re-evaluation of fertility status by checking all the reports of husband and wife again
Trial of In-vitro fertilization for having a child
And then repair of the hypospadias from urinary point of view once wife if pregnant.

Both for the patient and the surgeon, it is very important to have the goals and expectations from any treatment set at the beginning of the treatment itself. VK had come to me with a primary issue of infertility and the secondary issue was urinary splaying due to incompletely repaired hypospadias. By solving his hypospadias issue, we could not have solved his infertility problem and I did not want him to have any false hopes and thus get surgery done for the wrong reason/ indication. Overall, VK was very happy with the plan. I hope that he will have a baby soon and then we will fix his rest of the urinary issues in a single stage and well.

Over the last few years, our team – myself and Dr Manish Dubey have treated about 20 adults with various kinds of hypospadias and residual problems. Some of these have been for urethral fistulas, others for residual chordee or cosmetic issues. Most of these have come just before marriage or when they are facing issues such as VK. A couple of patients actually travelled from south India and one from Dubai to get treated.

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