The Usual Questions about Hypospadias by Parents

Nothing is better than actually quoting the questions posed by parents and answering them as I would do in my clinic. So here is a set of questions asked by a very concerned father recently on an email and I have tried my best to answer them using my last few years of experience in working closely for children with Hypospadias.

Dear Dr Singal, This has reference to your consultation at MITR Healthcare Hospital for my son Master  XXXXX (6 months old) on xx/xx/xx. My son was diagnosed with Hypospadias soon after birth and was advised for correction surgery. We are basically from xxxx city and I was visiting my in laws at that time and took my son to you for consultation. After consultation you had advised a single stage surgery.

My wife and myself have decided of doing the surgery from you in Navi Mumbai at a hospital which you will advise. As parents it is difficult for us to accept the fact that my son have such problem and at such a tender age he has to undergo surgery, I hope you are able to understand our situation and feeling. As parents I have some queries regarding the surgery. 

1. How long will the procedure take?

Answer: The surgery for hypospadias (urethroplasty) can take anywhere between one hour to three hours depending on the severity of hypospadias, associated bend in penis (chordee) and type of surgery performed. In your son’s particular case, since he has a penoscrotal hypospadias my assessment would be that since this is a moderately severe hypospadias, the surgery may take about 3 hours.

2. Will he be given general anesthesia?

Answer: For minor hypospadias surgeries lasting less than 2 hours, we generally give regional anesthesia (caudal epidural block) for pain control/ relief with sedation (so that the child sleeps comfortably throughout the procedure). Hypospadias surgeries needing longer time than that generally require full anesthesia and I guess that will be the situation with your son’s surgery.

3. Will he be 100% cured after the surgery. I mean to say will he be able to stand and pee/urinate like other male child?

Answer: Results of surgery for hypospadias have improved considerably. Please read this blog for more information- http://www.hypospadiasfoundation.com/hypospadias-blog-by-dr-a-k-singal/how-to-prevent-failures-in-hypospadias-surgery-urethroplasty/ buy kamagra online

Currently, more than 90% of the children with penile hypospadias get successful results after single stage surgery and children are able to stand and pee like a normal kid a few days after surgery. In some children, a minor second surgery may be needed if there is a fistula or a stricture.

4. Will his penis look normal like others?

Answer: During hypospadias surgery, we usually take tissue from extra foreskin on top and use the rest of it to provide equal skin cover on all sides to penis. At the end, the penis has a circumcised appearance. Also, if there has been any bend in penis, that is corrected leading to straight penis after surgery. So in nutshell, in most of the cases a few weeks after surgery, penis looks like just that a circumcision has been done.

5. Will the surgery affect his sexual life later on? I mean to say will there be any issue regarding erection, semen ejaculation etc?

Answer: Generally with current surgical techniques preserving nerve and blood supply, the repairs have resulted in very good outcomes both from cosmetic and functional perspective. Some children who have undergone a flap procedure for a severe hypospadias such as for scrotal hypospadias may need an evaluation as the force of semen ejaculation may not be very good. Also a check-up is mandatory later on after puberty at about 13-24 years of age and after 2-3 years of sexual life/ marriage to ensure that the urethra is functioning well.

6. I have gone through internet a little bit and have understood there are few types/methods of the surgery like inverted Y tubularised Plate etc. I would like to know for him what surgery will be undertaken.

Answer: For Hypospadias, more than 100 different types of repairs have been described in last two centuries. Some of these have become outdated with new knowledge. Currently, about 7-8 types of hypospadias repairs are done by hypospadiologists worldwide and these include Tubularised Incised Plate Urethroplasty (Snodgrass Procedure), Onlay flap, Prepucial tube, Glans approximation procedure, Barcat Procedure, two stage urethroplasty- Thiersch duplay type, Modified Koyanagi repair etc. The type of repair is dictated by the type of hypospadias and expertise/ comfort of the surgeon with a particular repair.

7. For how long he will have to be hospitalized and what care should be taken post surgery.

Answer: We generally admit the children in morning and do the surgery in the first half itself. Most of the children are able to go home either in the evening or the next day morning. We try to send them home as soon as possible – more info here: http://www.hypospadiasfoundation.com/hypospadias-blog-by-dr-a-k-singal/evolution-in-hypospadias-management/

Some children who have undergone very complex repairs, or surgery for failed hypospadias or come from outside the city – may need to stay for a longer period of time. The post-operative care includes giving medicine on time, regular double diaper changes and regular follow-ups. The child can take normal diet by evening and can play within the house.

8. How regularly follow ups are required?

Answer: After discharge, we generally call the baby for removal of dressings on day 4-5 and removal of catheter on day 7-10 depending on the type of hypospadias. Sometimes the urine catheter may be kept for 12-14 days in complex hypospadias repairs. Then a further follow-up is needed at 1 month after surgery and then 6 months and 2 years after surgery. Another assessment should ideally b done at 13-14 years of age and later on in adulthood once sexual activity has started.

9. What complications apart from fistula can happen also how soon can we come to know whether a 2nd surgery is required or not?

Answer: Other possible complications after Hypospadias Surgery are

a)      Bleeding -Usually rare, minor and stops in 2-3 days.

b)      Infection- less common and even if it occurs is usually superficial and resolves with antibiotics

c)      Fistula

d)      Meatal stenosis: Narrowing of the urinary opening can occur and may need regular calibration or minor cut back called meatotomy in some cases

e)      Diverticulum: This may be seen after a flap repair for hypospadias as the skin flap expands and balloons during passage of urine. With careful trimming of the flap during surgery, this has become much less common.

f)       Stricture: Sometimes during the healing phase, the new urethral tube may become narrow and require further treatment. This is noticed by poor stream, straining during passage of urine and long time taken to pass urine. This may require further treatment in form of dilatation or a second surgery.

g)      Dehiscence/ breakdown: Very rarely, the whole repair may breakdown due to poor healing, infection or loss of blood supply requiring 1-2 more surgeries. This is very uncommon and unfortunate.

We generally get to know about the need for second surgery with respect to fistula by about 1 month after surgery while some other complications like stricture or stenosis or diverticulum may not be apparent till 5-6 months.

Last lines by parents: Please do not misunderstand as we are really very concerned and worried about this and hence we are asking these to you. I look forward for your replies in this aspect. Sorry for asking so many questions.

Answer: Please do not hesitate to ask any questions which you might have. They may sound trivial or silly but please do not have these lurking in your mind. Once we decide to work as a team to get your child better, we should be on the same page and clear all the doubts before surgery. We should also be having the right and identical expectations from the surgery.