Hypospadias is very common congenital birth defect of penis. Most of these children require surgery in childhood. The accepted rate of complications after hypospadias repair in less than 20% in sever and under 10% in milder distal or midpenile hypospadias. When the first surgery for hypospadias fails, the children may need a second redo surgery and in some cases third or more surgeries. Such cases are best managed and treated by expert hypospadias surgeons or hypospadias specialist doctors.
Master AKM was born in Mumbai India. He was noted to have severe proximal penile hypospadias. He underwent one hypospadias repair at the age of 5 years and another one at 8 years of age. He developed pain in passing urine and used to really cry at time of passing urine. The treating surgeon at a top mumbai hospital, tried to open the urethra by taking under anesthesia and dilating 3-4 times but the symptoms of pain while passing urine returned again and again.
Finally, the parents came to Hypospadias Foundation in Navi Mumbai and contacted us. The child was attended to by Dr A.K.Singal, Pediatric urologist & hypospadias surgeon. On examination, Master AKM had pus at the new opening of penis which was little under the head of penis even after previous multiple surgeries. The penis skin also looked unhealthy and hard at places. The child was admitted and given antibiotics by injections. Parents were explained about the serious condition and that cystoscopy will be needed to check the reason for child’s difficulty in passing urine.
During cystoscopy, it was realized that the new urethra made during surgery had all become very tight (Stricture). The urethra beyond penile region was also unhealthy till bulbar region near prostate gland. A condition called BXO (Balanitis Xerotica Obliterans) was suspected as the cause of the stricture. Dr Singal discussed with family for the need to open the entire urethra till prostate gland and then put skin from inside the mouth on underside of penis (Buccal mucosa) and then come and do the second stage surgery after 6 months. The parents agreed for the plan for staged buccal (oral) mucosa graft urethroplasty.
The urethra was opened on the underside of penis till bulbar region. Long buccal mucosa graft was harvested from right inner cheek. Since a long graft was needed, another buccal graft was taken from the lower lip (labial oral graft). For the proximal urethra- cheek buccal graft was placed as dorsal inlay graft and urethra was closed till penoscrotal region. From Penoscrotal region till glans- buccal graft from lip and cheek was placed, fixed and left open. A tie-over dressing was done to fix the graft and help in graft uptake.
After 6 months, the graft looked pink, healthy and soft. Second stage urethroplasty was finished over 8 Fr catheter as the graft and surrounding tissues looked supple now. Dressing was removed on day 5 and catheter was removed on day 10. AKM passed urine well after catheter removal with excellent healing of the tissues. We did a uroflowmetry to check flow of urine, it showed an excellent flow rate of 25ml/ sec. AKM remains well after two years of surgery and is growing up to be a smart young man. He and his family have put up all bad memories behind them and are keen to help other families who have kids suffering from hypospadias.
About buccal mucosa graft urethroplasty:
Buccal (oral) mucosa is inner lining of mouth (Cheeks, lips) and is a very good layer to be used for redo surgery in failed hypospadias. Buccal mucosa urethroplasty (also called oral mucosa graft) is recommended when there is shortage of skin on the underneath of penis and there is no residual prepuce (foreskin). Hence, buccal grafts have no role in primary or first surgeries for hypospadias.
Parents often get very worried and alarmed when we as hypospadias surgeons tell them that we will take the skin form the mouth to make urine passage in penis. The reasons are:
About the author:
Dr A.K.Singal is a renowned Pediatric Urosurgeon and one of the best hypospadias surgeons in India. At hypospadias Foundation in India and Bahrain, he takes care of more than 150 kids and adults with primary and failed hypospadias. Hypospadias foundation is located at MITR Hospital in Kharghar, Navi Mumbai, India and at Ibn Al Nafees Hospital, Manama, Kingdom of Bahrain.
With the team work, expertise, dedication, a bit of luck and years of experience in treating patients with complex, severe and failed hypospadias, at Hypospadias Foundation we are able to give them cure and their normal life back.