staged hypospadias repair Archives - Hypospadias Foundation

March 03 2024

Single stage hypospadias repair in a boy after multiple failed hypospadias surgeries

“Mast SP, a 15-year-old male from South Africa, is a case of failed hypospadias repair, having undergone four unsuccessful surgeries elsewhere in the past. Despite previous attempts, the desired result of hypospadias repair was not achieved. He presented to us with complaints of spraying of urine with residual chordee. On clinical examination, we found that the meatus was located at the coronal region. The penis was small with flat glans. He was planned for cystoscopy to assess the status of the native urethra, and redo hypospadias surgery was planned in a single stage or in two stages depending on the cystoscopy findings, addressing the challenges of hypospadias repair in a boy

1. Clinical picture showing coronal meatus.

Cystoscopy showed normal urethra. Since the majority of the urethra was normal, we planned for single stage repair, focusing on hypospadias repair in a boy. We chose to proceed with single stage distal oral mucosa inlay graft urethroplasty.

Chordee assessment was done at the start of surgery, and the patient did not have chordee, hence degloving was not done. A midline incision was given in the urethral plate to assess the quality of the urethral plate. There was no scarring in the urethral plate. Since the urethral bed was healthy, we planned to place an oral mucosa inlay graft and perform single stage urethroplasty.

2 a & b. Clinical picture showing the marking of the incision and chordee assessment.

Oral mucosa graft was harvested from the upper lip to perform hypospadias repair in a boy. The graft was defatted and sutured at the urethral bed using 5-0 vicryl. The graft was sutured at the edges of the urethral plate and was quilted in place using 5-0 vicryl sutures. Following inlay graft placement, glans wings were widely mobilized. Urethroplasty was done using 5-0 vicryl stitch, first layer was continuous subcuticular inverting sutures. Second layer was closed using local tissues. Local flap was harvested from the left side and sutured over the urethroplasty as a waterproofing layer using 5-0 vicryl. Glans wings were widely mobilized and distal urethroplasty along with glansplasty was done using 5-0 vicryl.

3 a & b Picture showing site of oral mucosa graft harvest i.e upper lip and oral mucosa graft, it has been placed and quilted in the urethral bed.

4 a & b: Distal urethroplasty completed and local flap harvested from the left side.

5 a & b: Local flap sutured over the urethroplasty, and second picture shows completion of the entire repair.

After undergoing hypospadias repair in a boy, the patient had a per urethral catheter and suprapubic cystostomy (SPC). Dressing change was done on postoperative day 4 followed by operated site inspection on every 4th day. Per urethral catheter was removed on postoperative day 21 and SPC was removed on postoperative day 22.

6. Picture showing status at post operative day 15 and second picture shows urine stream after catheter removal.

Post catheter removal, he was passing urine in single straight stream with no leak. Patient was started on meatal dilatation using meatal dilator with mild steroid ointment for 3 months.

Testimonial from the boy’s father in his own words:

We are from South Africa. We got reference of Dr. Singal from a website, post which I got an appointment. Post which they did a proper evaluation and told that he had to undergo a redo hypospadias repair. Based on the evaluation, he had to do redo surgery for hypospadias repair in a boy. We came here on 22nd of December, procedure was properly explained to us. The surgery went well, post care after the surgery was also extremely good. Total support staff, hospital staff took care of my son very well. After the surgery, the discharge process was very fine, post care after discharge was also very good. The steps were properly explained. Today we are finishing the treatment and going out of India to South Africa. From my experience, the overall procedure was very good and extremely satisfying.

Single Stage Hypospadias Repair In A Boy After Multiple Failed Hypospadias Surgeries

Failed hypospadias repair refers to a situation where the initial surgery to correct hypospadias was not successful. Inspite of the best efforts by the surgeon the complications may happen because every healing of every hypospadias patient is different. We do not know the exact reason for complications after hypospadias surgery but here are some factors which may contribute to post-surgery complications:

Severity of hypospadias: Severe hypospadias repair is more complex and more challenging than mild hypospadias. Total healing time in hypospadias is 3- 4 weeks and it is longer in severe hypospadias. To minimize the risk of complications in severe hypospadias repair, the entire repair may have to be done in 2-3 stages.
Surgical technique: Different surgical techniques have varying success rates, and the choice of technique can impact the outcome. The choice of technique depends on the type of hypospadias, degree of chordee, glans diameter etc. An expert hypospadias surgeon will choose the best technique after considering all the factors because no two techniques are the same, and no two hypospadias are the same.
Experience of the surgeon: The experience of a surgeon is an important factor for successful hypospadias surgery. Centre performing more than 50 surgeries per year will have lesser complications compared to the other centres.
Wound healing: Wound healing is an important deciding factor in complications after any surgery. In hypospadias, wound healing is very slow in adults as compared to children. This may be because of decreased cell turnover with age, a weakened immune system, and reduced blood flow. And if they have any preexisting co-morbid illnesses then healing is slower, with a higher risk of complications.
Age at surgery: The best age to undergo hypospadias surgery is between 6 and 18 months of age. If not done at this age, it should ideally be done by 5 years of age. Parents are sometimes unable to get the surgery done within 5 years of age, and these children, when they reach adulthood, realize that they need surgery to correct the hypospadias. Outcomes in later age are little inferior to childhood hypospadias surgery but still possible. Adults with hypospadias need not lose hope because it’s better late than never. At Hypospadias Foundation, we have been able to achieve good outcomes with cosmetic result with a success rate of more than 90%, even in adults after multiple previous failed surgeries.
Underlying medical conditions: Obese or overweight adults, smokers, poor nutritional status, and diabetes are some of the conditions that can lead to slow healing. Overweight patients or diabetics can develop insulin resistance, causing poor healing. Smokers, nutritional deficiencies, etc. can cause decreased blood flow to the operated site, associated with decreased collagen production, which in turn causes slow healing.

Impact and Considerations after failed hypospadias repair:

A failed hypospadias repair can have both physical and emotional consequences for an individual with adult hypospadias and for parents of kids suffering from hypospadias. Complications that can occur after hypospadias repair are:

Urinary problems: difficulty in urinating, spraying of urine (glans dehiscence), urine passage from multiple holes (fistula), pain in urinating, or urinary tract infections, swelling pf penis during voiding (diverticulum), problems with ejaculation, post void dribbling,
Residual chordee (curvature): The penis may remain bent, affecting sexual intercourse and, in turn, leading to sexual dysfunction.
Cosmetic appearance: The meatus may be at a slightly lower level than normal. This may be disturbing for some individuals. In this case, there will be no problems in passing urine, and it is merely the way it looks different from others.
Psychological impact: As a parent, you may feel helpless and angry after a failed hypospadias. Failure of hypospadias surgery can cause feelings of anxiety, frustration, suicidal tendency, and low self-esteem in an adult. At certain times, adults may need pre- surgery counseling to reduce anxiety and stress. By improving your communication with your doctor and understanding the risks and benefits of surgery, you are more likely to be satisfied with the outcome.

Seeking Help:

If you or someone you know has a failed hypospadias, it’s crucial to seek professional help from a urologist specializing in pediatric urology or hypospadias. They can assess the situation, discuss treatment options, and provide guidance and support throughout the process. Even after previous unsuccessful repairs, there is more than 90% chance that with an expert hypospadias surgeon, the complications can be managed, and your hypospadias can be fully cured.

About Hypospadias Foundation

At Hypospadias Foundation, we get adults and children from all over the world in search of treatment for hypospadias. We provide support and information for children, adults, and their families affected by hypospadias. Dr Singal and Dr Shenoy are deeply devoted to creating awareness and helping patients get the right treatment and best outcomes for hypospadias. Children and adults from more than 25 countries visit Hypospadias Foundation in search of treatment for hypospadias.

Dr A K Singal is a highly experienced surgeon and is regarded as the best hypospadias surgeon in India and in the world for treating children and adults with hypospadias. If you are looking for a highly skilled and experienced pediatric urologist and hypospadias surgeon for yourself or your child, then Dr Singal is an excellent choice.

Dr Ashwitha Shenoy is an expert pediatric surgeon with a special interest in pediatric urology and hypospadias. Dr Singal and Dr Shenoy’s collaboration allows them to offer advanced surgical techniques and comprehensive care for patients.

For appointment kindly contact us at the contact details given below.

MITR hospital & Hypospadias Foundation, Kharghar, Navi Mumbai, India – Tue/Saturday 4:00pm-6:00pm, Call for appointments: +91-9324180553 (whatsapp), +916262840940, +916262690790 Or email us at hypospadiasfoundationindia@gmail.com

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January 01 2024

Two stage oral mucosa graft repair in redo hypospadias

A 3 year 6 months male child presented to us in the OPD after two failed surgeries for hypospadias (done elsewhere). He had undergone a staged hypospadias repair at another centre in Mumbai and when he came to us, he had meatus at the proximal penile region probably due to complete dehiscence after stage 2 repair. The child was very apprehensive in the OPD because of a traumatic experience from previous surgery. On examination, the meatus was in the proximal penile region with very irregular unhealthy skin beyond that. At our centre, he was planned for cystoscopy, chordee assessment and most likely a staged oral mucosa graft hypospadias repair for best outcome.

On clinical examination, the meatus was at the proximal penile region with
unhealthy distal skin.

At the start of hypospadias surgery, chordee was assessed and there was no residual chordee noted. Deep degloving was done, all fibrotic tissues from the urethral bed were removed. Proximal urethra was mobilized. Chordee was reassessed and no chordee was noted. Skin was rearranged on the dorsal and ventral side. Raw area of 4x2cm was noted on the ventral aspect. Hence, we planned a stage 1 OMG repair i.e placement of oral mucosa graft.

Oral mucosa graft was harvested from the right cheek and placed on the ventral side from the glans till the meatus. Graft was quilted thoroughly on the corpora using 6-0 PDS.

Chordee was assessed, no residual chordee noted. Deep degloving done, all fibrotic tissues excised.

Skin rearranged on the dorsal and ventral side. 4cm raw area on the ventral side noted.

Oral mucosa graft harvested from the right cheek of size 4x2cm. Oral mucosa graft sutured on the ventral side from the glans till all around the meatus.

After stage 1, graft healing was good. Steroid massage was started 3 weeks after surgery and was continued for 5 months. Graft uptake was 100%. Second stage was planned after 6 months when the graft was soft and pliable. During the second stage hypospadias repair, chordee was reassessed and no chordee noted. Local anaesthesia – lignocaine with adrenaline was injected at the edges of the graft. Graft was incised at the margins and tubularized over a 7Fr Infant feeding tube (IFT). Second layer was closed using local tissues. Dartos flap was harvested from the left side and sutured over the urethroplasty using 6-0 PDS. Glans wings were widely mobilized and Glansplasty was done using 6-0 PDS. Glans epithelium was closed using 6-0 PDS. Skin was closed in 2 layers using 6-0 PDS and 6-0 vicryl rapide.

Graft was soft, 6 months after stage 1 repair. Chordee was assessed and no chordee was noted.

Graft was measured and 18mm width was used for urethroplasty. Graft was incised all around and tubularized and sutured using continuous inverting subcuticular sutures using 6-0 PDS.

Dartos flap sutured over the urethroplasty. Glansplasty and skin done hence completing Stage 2 OMG urethroplasty.

Dressing change was done after 7 days, and catheter was removed after 10 days. After catheter removal, the child passed urine in single straight stream with no pain or leak.

Post catheter removal, passing urine in single straight stream with no complications.

Two stage oral mucosa graft repair in redo hypospadias

Hypospadias is usually diagnosed after birth in the neonatal period by a pediatrician. Once diagnosed, referral to a pediatric urologist is necessary to plan surgery at the right age. As per the guidelines the best age for hypospadias surgery is between 9 to 18 months. Hypospadias Surgery is planned in single or two stages depending on the severity of hypospadias. After chordee correction, usually there is insufficient skin on the underside of the penis to reconstruct the urethra hence extra tissues either in the form of prepuce (in primary ones) and oral mucosa graft (in redo cases) are used for urethroplasty.

Prepucial skin can be mostly used only once for the hypospadias repair. If the first surgery is unsuccessful then we need to plan redo surgery by using skin from somewhere else due to lack of local prepucial skin. In these children, use of oral mucosa graft is an excellent option. The reason why oral mucosa can be used for urethral reconstruction is because it is hairless, thin and pliable similar to the natural lining of the urethra. Graft is harvested from the inside of the cheek or lip, fatty tissue from the graft is removed. The penis is prepared for placement of the graft and the graft is meticulously sutured on the corporal bed. The graft incorporates into the urethral bed and becomes soft in 6-8 months. Local Steroid massage is necessary to make the graft soft. Once it is as soft as lip it can be tubularized to form the neourethra. The beauty of oral graft is such that there is less risk of fistula formation, minimal donor site scarring and has good cosmetic outcomes. However, it requires specialized skill and experience to perform oral mucosa graft in hypospadias and there is a small percentage of adults or children who may develop graft rejection or failure. In these children or adults, we need to replace the graft completely by a new graft.

The above-mentioned case is of a boy who presented to us after two failed hypospadias surgeries in the past. The local prepucial skin was unhealthy, hence we opted for oral mucosa graft. The final cosmetic result in this boy was excellent and he was able to pass urine in single straight stream with no complications.

At Hypospadias Foundation in Navi Mumbai, after hypospadias repair including oral mucosa inlay graft urethroplasty, children are encouraged to walk, play, and do some activities at home comfortably. We do not advice bed rest. Tying the legs and restricting children from doing activities or walking is disturbing for the child. Encouraging them to do activities can act as a distraction and take their mind off from the discomfort and promote healing. With our vast experience in hypospadias, we would recommend that children be allowed to do some activities in the post operative period. Play can be powerful tool for children to express their emotions and process surgical fear.

About Hypospadias foundation

Hypospadias foundation is an organization dedicated for children and adults with hypospadias and is rated as the best hospital for hypospadias repair in India. It was founded in 2008 by Dr A K Singal and is located in Kharghar, Navi Mumbai. Hypospadias foundation offers best results for surgical repair for primary and failed hypospadias. We at hypospadias foundation believe in providing personalized care and psychosocial support to families of children and adults with hypospadias. The foundation also advocates improved access of care for people with hypospadias around the world.

Dr A K Singal is a well renowned hypospadias surgeon and regarded as the best hypospadias surgeon in India and in the world. His vision for hypospadias has helped him achieve excellent outcomes in adults and children with hypospadias. He has dedicated his life in treating children and adults with hypospadias with his innovative surgical techniques.

Dr Ashwitha Shenoy is an expert pediatric surgeon with special interest in pediatric urology and hypospadias. She holds a particular interest in hypospadias and along with Dr Singal performs advanced surgical techniques for both primary and complex hypospadias cases in children and adults.

Contact us:

For appointment kindly contact us at the contact details given below.

MITR hospital & Hypospadias Foundation, Kharghar, Navi Mumbai, India – Tue/Saturday 4:00pm-6:00pm, Call for appointments: +91-9324180553. Or email us at hypospadiasfoundationindia@gmail.com

or pls call up our clinic for an appointment – +91-9324180553

April 04 2015

What is chordee (bent penis) and why do hypospadias have chordee? How is chordee correction surgery done?

Chordee means that the penis is bent (curved penis). Penis mostly gets bent downwards hence it is called ventral chordee and is seen commonly seen in children with hypospadias. In children with other type of anomaly which is much rarer than hypospadias called epispadias the penis may be bent upwards, it is called dorsal chordee. Hypospadias is atleast 20-30 times more common than epispadias, hence when someone uses the word chordee it is by fault supposed to mean ventral chordee as seen in hypospadias.

Why does chordee happen?

When the penis is getting formed between 8-12 weeks of pregnancy, the urethra (urinary passage) also starts getting formed from the base of penis to the tip of penis. This happens gradually under the 3influence of male hormones produced by the testis. All around urethra, a special tissue called corpus spongiosum is also formed through which the urethra runs. The two cylinders of tissue called corpus cavernosa are also formed. Together equal sizes of spongiosum and two cavernosa cylinder are responsible for a straight penis. When the urethra is short as in hypospadias, the spongiosum tissue is a3lso short, the skin and dartos tissue under skin is also short and sometimes the corpora can also be curved. Hence chordee results from this shortage of these tissues on underside of penis.

Do all hypospadias have chordee?

Chordee is seen more than 50% of all hypospadias but this also depends on the severity of hypospadias. Generally, the more severe the hypospadias is, higher the chances of chordee. Hence, chordee is more common in scrotal hypospadias than distal penile hypospadias. This is a generalization and it is not true in all cases as we have seen lot of cases of chordee without hypospadias and also minor hypospadias having a major degree of chordee.

How is chordee checked and graded?

Chordee can sometimes be seen by the parents when the child has an early morning erection which happens even in small babies. Generally we tell the parents to click the picture from the side to document the chordee degree. Chordee must always be checked during hypospadias surgery by doing an artificial erection test. This is infact a mandatory test for all hypospadias and the most important thing to be taken care of during hypospadias surgery. If chordee is not checked and left untreated, it can create lot of issues in adulthood and need surgery again which is much more difficult in adulthood. Chordee is graded in degrees like 30 degrees, 45 degrees or 90 degrees or also as mild, moderate or severe.

Does chordee always need surgery repair?

A straight penis is important to have straight stream of urine as well as for having normal sexual intercourse. Hence, if the penis has anything more than 15-20 degrees of bend should be corrected.

How is chordee repair surgery done?

Degloving of penis: In any hypospadias surgery or chordee repair surgery, the first step is called degloving of penis. Degloving means that the penis skin is taken down till the base of penis by a circular incision around head of penis while saving the opening of hypospadias and urethral plate. Generally, there are some abnormal tissues around base of penis which cause chordee and once these are divided chordee gets corrected in most cases. Then a tourniquet is applied on the base of penis and saline solution is injected into the head of penis or corporal bodies. This is called artificial erection test and allows the hypospadias surgeon to assess the degree of chordee.
Tunica albuginea plication: If there is still chordee then further steps need to be done to correct chordee. If the chordee is mild, then we perform tighten the top side of penis with a non-absorbable stitch to straighten the penis.
Division of urethral plate: If the chordee is still severe then a cut needs to be given to divide the urethral plate between hypospadias opening and the head of penis.
Dermal graft for chordee correction: Chordee is again checked and if it still severe then corpora needs to be lengthened by placing a dermal graft on underside of penis. In case a dermal graft is placed, then a single staged repair can’t be done and a staged hypospadias repair is done.

It is important for a hypospadias surgeon to make sure that the chordee is completely corrected during hypospadias surgery. It requires experience to do a stepwise assessment of the chordee in every individual case and then proceed with chordee repair as detailed above. The importance of having a straight penis cannot be overemphasized.

About the author:

Dr A.K.Singal during Hypospadias surgery

Dr A.K.Singal is a renowned Pediatric urologist and is one of the best & most experienced hypospadias surgeons across India and world. His deep interest, research, knowledge has helped hundreds of children and adults with hypospadias achieve a satisfactory cosmetic and functional results of hypospadias. Dr Singal is available in Fortis Hospital in Mulund Mumbai, Jupiter hospital in Thane, Fortis Hospital in Vashi (Navi Mumbai) and MITR Hospital & Hypospadias Foundation in Kharghar, Navi Mumbai, India. To reach him you can send him an email at hypospadiasfoundationindia@gmail.com or fill up this form:

Contact form for Dr Singal

Also, you can call up Dr Rajkumar, Dr Singal’s assistant and Coordinator of Hypospadias Foundation on +91-9821261448

Video of Glanular Hypospadias with chordee surgery repair by Dr A.K.Singal

Video of Distal penile hypospadias repair procedure by Dr A.K.Singal

Video of proximal penile hypospadias repair surgery procedure by Dr A.K.Singal

Video of scrotal hypospadias single stage repair procedure by Dr A.K.Singal

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Tag Archives: staged hypospadias repair

Single Stage Hypospadias Repair In A Boy After Multiple Failed Hypospadias Surgeries

Contact Form for Hypospadias Foundation

Two stage oral mucosa graft repair in redo hypospadias

About Hypospadias foundation