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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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.

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    How to prevent failures in Hypospadias Surgery (Urethroplasty)

    Hypospadias is a complex and challenging clinical problem. Worldwide accepted failure rates for single stage hypospadias repair (urethroplasty) are 5-10% and these children who have encountered a failure require a second surgery. This situation is never pleasant for the surgeon or the parents or the child who is actually undergoing another surgery. The key thing to understand here is that everyone including the parents and the doctors are on the same side in this situation and everyone wants the child to get better.

    Infact when the parents come and see me in the clinic and ask about my second surgery or failure rates – I often tell them “I want your kid to have only one surgery, you want your kid to have only one surgery and the whole reason why you came to meet me and came to know that there is someone called Dr Singal is that your son has hypospadias. Our goals are, thus, aligned towards pursuing a good result with only one surgery in mind but at the same time realizing that inspite of our best intentions and experience and all the money and the efforts, 5% of the kids may still require a second surgery. Another reassuring fact is that the second surgeries are often minor with faster recovery and overall at the end of it all the child would be absolutely normal in almost all the cases. The only difficulty is to assess with full surety which child will have a failed surgery. For the child whom the second surgery becomes a reality the individual failure rate is thus 100% and for the rest the result is 100%”

    Fortunately, there are some fine pointers which tell us about the increased risk of second surgery. These are:

    • Severe hypospadias
    • Severe chordee (the penis is very bent)
    • Associated issues like chromosomal problems or disorder of sex development.

    The steps which one takes to avoid failure in hypospadias have to be titrated for each case thus giving each child undivided individual attention and care. Some of the mantras in avoiding pitfalls are:

    • Spending enough time to understand the subtle nuances and variations in anatomy of every case.
    • Proper selection of technique of surgery- single most important step in ensuring good outcome. There are over 100 techniques described for hypospadias repair. Most of the surgeons master 4-5 techniques and then for every case we have to diligently assess and assign a technique. This is best done at the time of surgery in the operation theatre. That is why a proper training, experience and dedication is very important in assuring good results. Pediatric urology training allows a surgeon to be flexible in the approach and decide at the last moment and even change the technique if something is not working out. It is akin to waiting for a ball to spin and then playing a shot called “late cut” in cricket. The whole hypospadias repair mirrors that philosophy.
    • A thorough re-operative assessment of the child for nutritional and health status is very important. The hemoglobin should be atleast 10gm% and the overall child should be well nourished so that the tissues will heal faster and better after surgery.
    • Fitness for anesthesia: Hypospadias surgeries require general anesthesia for the child. It is very important that blood tests and urine tests are normal for the child. Also, a very good clinical examination is done to make sure that the child does not have any other coexisting abnormality of infection such as chest infection, cough, cold, diarrhea or skin infection. Infection anywhere in the body makes the body weak as the body is consuming energy in fighting the infection and thus healing would be delayed. Also, there is a risk of a cross infection in the operated area. Since hypospadias is not an emergency, ideally we should wait till the child is fully well and in the “Pink of the health” (so to speak) before surgery.
    • Planning the surgery in a dedicated, good, well equipped & sterile operation theatre to prevent infection
    • Having microsurgical instruments which are dedicated only towards hypospadias repair and not used for any other surgery. Infact I personally have 3 such sets allowing me to sometimes perform 2-3 hypospadias repairs in one day
    • Using a magnifying loupe during surgery to perform surgery with finesse. Magnification helps in proper and fine dissection of tissues. Also the stitches used are of very fine caliber so magnification helps in tying knots properly.
    • Working with fine sutures- this goes hand in hand with using magnification since using magnification allows surgeon to use finer sutures.
    • Trained staff for surgery and post-operative care.

    In the end it is important to remember that for a child with hypospadias, first surgery is the best chance at a complete functional and cosmetic result. Pediatric Urologist and the medical team should make sure and do whatever in their power to give the child a 100% result in the first stage.
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      Evolution in Hypospadias treatment

      Hypospadias management has undergone big changes in last two decades. The results and outcomes of surgery have improved tremendously making hypospadias management a lesser headache for the doctor and the parents. Two decades back the results for hypospadias surgery were not so predictable and the surgeons and the family all used to be ready for mentally and financially for 2-3 surgeries and that too with suboptimal cosmetic and functional results.

      Some of the things which have helped this change are:

      • The newer techniques of  single stage urethroplasty (hypospadias surgery) such as onlay flaps,  Snodgrass repair and prepucial tube repairs.
      • Newer and finer sutures to do the surgery such as PDS, monocryl and vicryl rapide
      • Fine microsurgery instruments for doing surgery on delicate penile tissues
      • Uniform use of optical magnification by surgeons while doing surgery
      • Day care surgery avoiding long hospitalization and infact the whole focus is on sending the children home the same day in most cases
      • Good antibiotics and  pain relief in post surgery period
      • Early age at surgery – Surgery is nowadays usually done at 6-9 months of age for a child who is otherwise well
      • Trained surgeons and teams dedicating time and energy towards giving a good outcome in children with Hypospadias
      • Surgeons with mindset firmly towards doing a single stage repair. Mindset change has been a key catalyst towards single stage surgeries.

      For a penile hypospadias whether it is mild, moderate or severe (distal, mid or proximal penile), the success rates for a single stage urethroplasty are close to 95% now; meaning that only 5% of the children require a second surgery for urethral fistula and even lesser for a stenosis. This is very heartening and gives confidence to the family as well as the doctor treating children with hypospadias. For such cases, it has become like any other surgery now, the child comes to the hospital on the morning of surgery, gets the surgery done in 1-2 hours, goes home by evening playful, active and pain free. Only thing the parents need to take care is regular medicines and diaper changes. This is certainly a huge step from 1990’s where these kids were kept admitted in the hospital for a week or ten days while they recovered after surgery.

      At home children eat better, feel better, are with family and there are lesser chances of hospital acquired infections with resistant bacteria. Happiness and good food is a key ingredient for a child getting a favorable result and this component is often understated and misunderstood. Keeping the child for a prolonged duration of time in hospital only increases cost of the surgery, amount of medicines used, discomfort faced by family and also risk of hospital acquired infections.

      Surgeon training in Pediatric Urology also has a great bearing on the outcomes of hypospadias repairs. With advancing experience, depth of academic and anatomical knowledge, devotion of time to hypospadias is the key to better results seen for some surgeons. It is often said that in Pediatric Urology specialty, to have good results in hypospadias surgery is often the acid test. It may be easier to excel in Laparoscopy or Endourology but still challenging to provide uniformly good results in hypospadias. The repairs and the depth of knowledge and understanding required is challenging and first few cases are unpredictable with respect to outcomes and a lot of young surgeons get disheartened and stop investing themselves into the art and science of hypospadias management. First few failures often bring out the fears and some surgeons find it difficult to continue in this unsure scenario. I still don’t know a single surgeon who never had a complication with hypospadias repairs or has stopped having complications in hypospadias. They do happen even with the most dedicated & expereinced surgeons as medical science is often an imperfect science thus lending the term “I practice medicine” but with growing volumes or experience and most importantly using the catalyst of dedication the results can quickly become very good, predictable and measurable. The complication rates/ second surgery rates become manageable and suddenly it seems enjoyable.

      It is very important that a surgeon enjoys his work- it should be like meditation while doing surgery wearing magnifying loupes with all the attention solely on a 2 inch area trying to finish the nature’s unfinished business with human hands. When this happens, that is when the results are acceptable to the surgeon and the parents.

      Distal Penile Hypospadias repair surgery by Dr Singal

      Severe Scrotal Hypospadias- Single stage repair by Dr A.K.Singal

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        Why nobody talks about Hypospadias?

        Hypospadias is a condition where the urinary opening instead of being present at the tip of penis lies somewhere on the underside of penis. There may be an associated downward curvature of penis (called chordee) as well.

        Hypospadias is a common disorder, yet it never gets much public attention. If we just talk about the hardcore data – it is staggering!!

        1/200 boys has hypospadias and this translates to 30 lakh (3 million) Indians (both adult & children) having Hypospadias which has either got treated, ignored or there have been failed attempts at repair. Every year there are more than 75000 kids born with hypospadias in India. Multiply this by 4 and you will get the global scale of the problem.

        Inspite of millions of kids having hypospadias and recent reports showing an increasing incidence because of various environmental factors, it is shocking that so little has been done to help children with hypospadias. Right from creating awareness about hypospadias to dispelling myths about Hypospadias and then leading on to supporting these children in younger age with proper diagnosis, timely surgery, evaluation for associated issues and then making sure that they develop into productive citizens of the society – this is a massive task. It requires motivation, commitment and understanding of the complex interplay both from the medical personnel as well as the parents of the child.

        Maybe hypospadias affects the male organ, putting parents and family under pressure to hide the disorder and everyone is worried about the stigma a penile abnormality carries even if repaired. Having seen numerous children with Hypospadias and their families, I understand a bit of their side. This will improve only when society starts thinking of Hypospadias or for that matter any disorder affecting the reproductive system as a small aberration and that too fully correctable with latest treatments.

        With growing experience, instrumentation, commitment and requisite team building, the results of hypospadias surgery are better than before. Hypospadias correction or Urethroplasty gets performed before infancy is over, most of the children go home the day of surgery in their diapers and success rates of a single stage urethroplasty are more than 95% over all varying from almost 99% in distal hypospadias to 90% in proximal hypospadias.

        It takes years for a surgeon to hone skills which will provide a predictably good result and a standard of care. This may involve first, a medical school training (5.5 years), General Surgery training (3 years), Specialist surgery training in Pediatric Surgery (3 years) and then a Pediatric urology training (1-2 years) – so a long haul of 12 plus years and that’s not it. It takes a further of 1-2 years to establish a centre and then train the ancillary staff for managing these children.

        During training when I saw the hypospadias surgery for the first time, I never thought that I would get so attached to caring for children with hypospadias. The surgery was difficult, required immense concentration for a prolonged period of time with magnification glasses and fine instruments, and still the results were suboptimal. It all changed during my Pediatric urology stint at Nationwide Childrens Hospital, Ohio-USA with Dr Rama Jayanthi. Suddenly, hypospadias was no longer a mathematical impossibility. It seemed possible to get predictable results after all and see happy kids. From then on there has been no looking back.

        Operating on a child with hypospadias is still the most important task for me and it something I look forward to doing every day. It is like meditation, first surgery in the morning. Everybody is ready, the team is motivated about making a difference to a little kid and then we do our jobs with precision and in sync at MITR Hospital and Hypospadias foundation. The staff is trained in pre-operative and post-operative care.

        Infact it has been the dream of my closest friend, colleague and co-founder of Hypospadias foundation – Dr Manish Dubey to see kids walking around the hospital with pink bandages on their penis and balloons in their hands and, we made it come true last year on Childrens day (14 November) when we operated 3 kids with hypospadias in a single day.

        Inside everyone lies a hope, a positive current which carries us forward through our life. We also believe that with better management of the hypospadias on clinical as well incidental issues around it, the stigma around hypospadias will go away completely. The final calling will be when we see these young kids develop into normal citizens and raise their own families and hopefully invite us to attend their weddings.
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