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December 12 2014

Letter from Pune: Family thanks Hypospadias Foundation for good results of a single stage urethroplasty for scrotal hypospadias

Author Dr. A.K.Singal Categories Hypospadias Specialist

Hello Dr. Singal,

When we came to know our son is suffering from hypospadias, we being parents were
really worried for him. There were several doubts and fears running in and out through our mind. We were very tensed and concerned regarding his hypospadias repair surgery, overall result and further treatment.
We then visited many doctors in Pune but were unhappy and unsatisfied with their answers and process of treatment, until one day while surfing on internet we read about you and the hypospadias foundation run by you. Thumbs up for the great job you are doing by running this foundation and providing complete awareness among parents.
For first time when you examined our son and the manner you explained the entire
process of surgery and treatment, really raised positive hopes in us. Most of our doubts were cleared in the first meeting itself. We want to thank you from the bottom of our heart for undertaking our son’s surgery not only in positive way but also making it successful in the first stage. Due to your fair treatment and kind support we were able to cope with our son’s surgery and health. We really want all other parents as well whose children are suffering from hypospadias to undergo Hypospdias treatment at Hypospadias Foundation at MITR Hospital, Navi Mumbai and go back home smiling.

As our son is a hypospadias patient, we want to keep his name and identity confidential. We are ready to share our experience and contact details with the parents whose children are suffering from hypospadias any time offline.

Thanks,
Mr. & Mrs. K,

Pune

These letters are priceless to us. As a hypospadias surgeon, I owe it to our team for excellent results and patient happiness. Surgery is often just one of the things which makes successes and miracles happen. It is the larger picture – the dedication, thought process, commitment and most importantly the love which the surgical team can give. I can safely say that beyond the surgeon’s hands and nurses injections there is something else which cures a patient. It is love and faith and it runs both ways. Mr and Mrs K came and saw us three months back and they came with full faith and commitment to get their son better. It is not easy to get a surgery for your young child. It is much more easier to get surgery done for yourself rather than your child. I really wish to express my gratitude to the parents and families who give their little ones in our hands trusting us to do the right thing for their child.

Case summary for Master D.K.

Master D.K. was born with scrotal hypospadias and was advised by the pediatrician to see a pediatric urologist or a pediatric surgeon for Hypospadias repair surgery at 1-2 years of age. After multiple consultations elsewhere, they finally came to see us at MITR Hospital & Hypospadias Foundation in Navi Mumbai. Navi Mumbai is just 2 hour’s drive from Pune so family thought of taking a second opinion from us.

Examination of Master D.K. confirmed severe scrotal hypospadias with mild chordee. I counseled the family regarding the possibility of a single stage repair. I explained to them that our intent would be to repair the hypospadias in one stage but sometime 5-10% of the kids may need a second surgery if something doesn’t heal well after first surgery. D.K underwent hypospadias repair surgery in October 2014 using an Onlay Island Flap Urethroplasty. He recovered from surgery and anesthesia very fast and was walking around and eating normally the next day. Happy with his recovery from Hypospadias surgery, we discharged him the next day and he went home back to Pune the day after surgery. Dressing was removed after 5 days and urinary catheter a total of ten days after surgery. A follow-up visit after 2 weeks showed hypospadias repair site to be healing well and parents and we were both very happy to see. It is now almost two months after surgery and D.K is doing very well. I hope that he continues doing well though he will need follow-ups at three months, one year then at 5, 10,15 years of age as some minor issues can crop up later in some cases of severe hypospadias.

As of now, it is time to rejoice and I can also breathe a sigh of relief. And to top up the happiness, I got this letter from the parents, which makes all the hard work so much worthwhile. Such letters make my work a pleasure and operation theatre a playground. My best wishes to the family for a happy future for the kid.

About the Author:

Dr A.K.Singal is a renowned Pediatric urologist and one of the best Hypospadias surgeons in India. He is the founder of Hypospadias Foundation based in MITR Hospital, Navi Mumbai and regularly does hypospadias repair surgeries in Mumbai, Thane and Navi Mumbai.

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    December 12 2014

    Distal Penile Hypospadias in a child: Single stage repair surgery video using TIP urethroplasty (Snodgrass repair)

    Author Dr. A.K.Singal Categories About Hypospadias

    Distal penile hypospadias is the most common type of hypospadias in children. The urethral opening is located on the underside of penis but in last 1/3 of the penis. While some of the distal hypospadias may have an associated bend in penis called Chordee, most of the distal hypospadias may not have a chordee. There are many types of hypospadias surgery techniques described and the hypospadias surgeon selects the type of repair depending on the anatomy.

    The key factors in deciding the repair are:

    1. Severity of Chordee
    2. Severity of hypospadias
    3. Quality of urethral plate
    4. Experience of the surgeon

    Snodgrass repair or Tubularised incised plate urethroplasty was described by Dr Warren Snodgrass in 1992 and relies on using the natural tissues of penis on the underside for making a new urinary passage. The basic concept is midline incision of the open urethra from the urinary opening till the head of penis. This expands the urethral plate and allows it rolled into a new urethral tube which can heal very well.

    The critical steps are:

    • Degloving of the penis: Incisions are marked preserving the urethral plate and all the penile skin is taken down to correct chordee. This step doesn’t harm the nerve and blood supply of penis as that runs deep inside the penis.
    • Artificial erection test: After applying a tourniquet, artificial erection test is done to check for any curvature (chordee). If there is no curvature, urethroplasty can be started.
    • Chordee correction: In most of the children with distal hypospadias, degloving alone releases the bands on underside of the penis and chordee gets corrected. In some children with hypospadias, chordee correction may be needed. This can be done by either putting a stitch – Tunica albuginea plication or by dividing the urethral plate. Urethral plate division is needed only in patients with severe chordee. But once the urethral plate is divided, TIP urethroplasty can’t be done, other types of repairs have to be planned.
    • Glans wings: Urethral plate is dissected into glans, creating glans wings on either side which are mobilized deep. Midline urethral plate incision (TIP incision) is given to expand the urethral plate and then urethra is closed with a fine absorbable suture such as PDS or vicryl to construct the new tube. The sutures are taken in a subepithelial fashion to invert the mucosa.
    • Second layer coverage: If there is good corpus spongiosum around urethral plate, it is mobilized for spongioplasty to provide security from urethral fistula. We also routinely use Dartos flap to cover the urethroplasty and prevent complications such as urethral fistula.
    • Glansplasty and skin coverage: Glans wings are closed with absorbable sutures and excess foreskin on the top is divided in midline and brought ventrally for complete skin coverage. Midline closure is achieved after excising excess skin so that a pleasing cosmetic outcome can be sought.
    • Dressing and catheter: Though lot surgeons use bulky dressings after hypospadias surgery, we use mostly a Tegaderm (transparent plastic wrap) followed by a soft gauze dressing. The catheter is tied to the glans stitch and allowed to drip urine into the diaper.

    Follow-up and care after hypospadias repair surgery with TIP urethroplasty:

    Most of the children are discharged by the evening of hypospadias surgery. Antibiotic syrup, pain killers and antispasmodic medicines are given for a week’s time. The parents are taught double diaper care and we call the children for follow-up after 5-7 days for removal of dressing and catheter at the same time. The hypospadias dressing is removed in clinic itself and the parents are advised to apply an antibiotic ointment on the penis for 2-3 weeks. Bath can be given as soon as the dressing is removed. We call for follow-up two weeks after catheter removal and after 3 months if everything is healing well.

    About the author:

    Dr A.K.Singal is a renowned Pediatric Urologist and Hypospadias Surgeon practicing in western india in area of Mumbai, Navi Mumbai and Thane. He is counted as one of the best hypospadias expert surgeons in the world and every year manages more than 200 kids and adults with hypospadias. He started Hypospadias Foundation in 2008 and Hypospadias Foundation remains the world’s only organisation dedicated to children with Hypospadias. Children from more than 20 countries travel every year to India to consult for hypospadias treatment under his team’s care.

    Dr A.K.Singal during Hypospadias surgery

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    Watch Video of repair of glanular hypospadias with chordee by Dr A.K.Singal

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