Single stage buccal mucosa graft urethroplasty for an adult with failed hypospadias

Posted on February 3, 2019 by admin

Hypospadias is a common congenital birth defect which occurs in 1/150 boys in India. 20-30 years back the treatment for hypospadias was very not very successful as the procedure and surgical techniques very not very refined, the number of expert hypospadias surgeons focussed on treatment was less, sutures and instruments for hypospadias surgery were also very basic. With advancing knowledge and expertise, these days in 2019, the results of hypospadias repair (urethroplasty) are much better. A lot of adults in this century, underwent surgery as children way back in 1980’s and 1990’s and some of them did not get good results even after multiple hypospadias surgeries due to complications. Some of these people lost hope at a cure and did not pursue further surgery for failed hypospadias. At Hypospadias Foundation, we regularly get such young adults who come from all over India to seek best treatment and cure for Hypospadias. One of the new techniques to cure such adults with hypospadias is to use skin from inside the mouth for making new urethra- called oral or buccal mucosa graft urethroplasty. In hands of an expert surgeon, it has extremely good results.

Case History:

Mr A.G. 26 years old young man, engineer by profession, extremely smart and suave in nature, came to our hypospadias clinic one evening. He sat down and talked about the trauma of two failed hypospadias surgery which he underwent in Indore with a plastic surgeon. The last surgery was about 10 years back. He had lost hope for cure till he stumbled upon Hypospadias Foundation while searching online. He had come with a hope to get a cure for his hypospadias issue and get married soon. His present problem was thin stream of urine, pain while passing and leak of urine from underside of penis. On examination, his penis was straight (no chordee), he had a fistula in proximal penile region with thin unhealthy urethra. We sat with him and explained the plan to do a cystoscopy and check for quality of urethra and find out reason for repeated failure of surgery and then decide whether a one stage or two stage surgery is needed for full cure and best results of hypospadias surgery. A.G. agreed for the plan and wanted the best treatment.

Surgery:

On cystoscopy, we saw that his new urethra was thin and unhealthy. We cut it open from tip of penis to the site of fistula and actually little below that. We saw that the dorsal wall (roof of urethra) was healthy with minor scarring. We made a deep cut in the dorsal wall in the central midline. We took a buccal graft (oral or labial graft) from upper lip. The graft was fixed with absorbable sutures in the midline to form a part of the neo-urethra. The graft and surrounding urethral wall were rolled into a tube with absorbable sutures around a 14 Fr silicon catheter – all in one stage. The unhealthy skin was excised, and closure of skin also done in a cosmetic way. The catheter was removed after 3 weeks and at one month after catheter removal AG was passing urine in a thick stream without pain from the tip of penis. He was very happy and planning to get married soon. We advised him to marry atleast 6 months after hypospadias surgery. The new urethra is still a bit fragile for 3-4 months after surgery and it is better to wait for 6 months for intercourse (coitus/ sex) after surgery.

Buccal (oral) mucosa graft urethroplasty in adults:

An adult with multiple failed hypospadias surgeries, generally has no normal penile skin or prepuce left for hypospadias repair using local tissues from penis. Hence in such patients, it may be better to use skin from inside the mouth for making the new passage. The skin can be easily taken from inside of cheek or lips. The defect heals very fast and generally without much complications. The buccal graft adapts to penile location very well and has great long-term results in failed surgery. While some of these cases are suitable for a single stage surgery, some may require two stage surgery depending on the severity of the defect. Nonetheless, Buccal Graft Urethroplasty remains a great option with best long-term results for children and adults with Failed Hypospadias.

At Hypospadias Foundation in India, Dr Singal and his team have one of the best hypospadias surgery results in the world. Children and adults from more than 20 countries such as UAE, Bahrain, Iran, Iraq, Afghanistan, Saudi Arabia, Pakistan, Bangladesh, Malaysia, Tanzania, Nigeria, Congo, Ethiopia, Kenya, Nepal, Indonesia, Egypt, Jordan etc come for treatment at our foundation. It is indeed heartening to see them go back with final cure from hypospadias.

To contact us write an email to hypospadiasfoundationindia@gmail.com or contact us at +91-9821261448 between 9am-6pm India time or fill up this form for enquiry.

Watch Buccal Mucosa Graft Urethroplasty Video here:

Watch Two staged Buccal Mucosa repair surgery in a child:

 

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Posted in Adult hypospadias,Failed & redo Hypospadias,Hypospadias Specialist,Hypospadias surgeon India,Hypospadias surgery video,Success Stories | Posted by admin | Posted on February 3, 2019 by admin | Tagged after hypospadias surgery, best hypospadias hospital, flap repair for hypospadias, hypospadias clinic in india, hypospadias surgeon bhopal, hypospadias surgeon in MP, hypospadias surgeon India, hypospadias surgery india, one stage surgery for hypospadias, onlay flap urethroplasty, onlay island flap hypospadias repair, results of hypospadias, results of scrotal hypospadias surgery, scrotal hypospadias, scrotal hypospadias repair, scrotal hypospadias surgery, severe hypospadias, single stage urethroplasty, urethroplasty for scrotal hypospadias

From Assam to Navi Mumbai – A child with Failed Hypospadias surgery treated by Buccal mucosa graft urethroplasty at Hypospadias Foundation

Posted on January 10, 2019 by Dr. A K Singal

Hypospadias repair surgery all over the world is done by surgeons from various fields such as Pediatric Urologists, Pediatric Surgeons, Urologists and Plastic surgeons. Considering that the number of children who suffer from Hypospadias is very high (almost 1 lakh in India every year and 3 lakhs all over the world), and that there are very less number of pediatric urologists in India (less than 10) it is obvious that majority of hypospadias would not be able to reach a pediatric urologist for best hypospadias treatment. That being said, results of the hypospadias surgery depend on the experience and interest of the surgeon in treating children with hypospadias more than the degree. Once a surgeon is doing more than 50-60 hypospadias repairs every year, the results of hypospadias surgery improve significantly. The accepted rate of complications in hypospadias correction is less than 25% in proximal severe hypospadias and less than 10% in more common distal or midpenile hypospadias. The children who have a failed hypospadias surgery may need a second surgery and in some cases even more surgeries. These failed hypospadias surgeries must be done by a hypospadias specialist or an expert hypospadias surgeon for best results.

Master A.R was born in Dibrugarh (Assam) and was noted to have a distal penile hypospadias. He underwent hypospadias repair surgery at Dibrugarh, Assam by a Pediatric surgeon at 2 years of age. After hypospadias surgery, he was kept in hospital for 10 days but upon removal of dressing he was noted to have complete breakdown of the hypospadias repair. His urinary opening had regressed back to the same location. Parents were very disturbed by the outcome and the treating doctor told them a second surgery will be needed in 6 months. Parents consulted surgeons in Calcutta (Kolkata) for second opinion for hypospadias but were not happy with their proposed approach. They came to know about Dr A.K.Singal, Hypospadias specialist surgeon doctor at Hypospadias Foundation in Navi Mumbai and contacted us. Finally, in November 2014, the family traveled from Assam in search for second surgery and complete treatment for Failed Hypospadias of their son.

On examination, Master A.R. had a complete dehiscence (breakdown) of the previous hypospadias repair and the urinary opening was still in distal penile location. The glans was open and there was excess skin on one side of penis due to previous surgery. The urethral plate was practically non-existent probably due to scarring from first hypospadias surgery. Parents were explained the various options for the second stage repair for hypospadias. Since there was some extra skin on one side we planned to use parts of it for final repair or use the buccal (oral) mucosa graft (lining of mouth either from cheek or lip).

During surgery, we observed that the skin on the side of the penis had a poor blood supply and was unsuitable to be used for onlay flap for urethroplasty. The second option was to use a buccal mucosa graft either in two stages or in one stage as an inlay graft. We decided to place the graft first as an inlay graft and then decide whether we can do the repair in single stage or do it as a staged urethroplasty. We harvested a 3 cm x 1 cm graft from the lower lip and defatted it nicely. We opened the urethra till we found a normal caliber urethra with thick walls. Then a midline deep incision was given in the urethral plate and graft was sutured in place with very fine absorbable sutures (6-0 PDS). This expanded the urethral plate especially in the head of penis (glans). Single stage inlay buccal (oral) mucosa graft urethroplasty was finished over 8 Fr catheter. Dressing was removed on day 5 and catheter was removed on day 10. A.R. passed urine well after catheter removal with excellent healing of the tissues. Though, he developed minor meatal stenosis (tight opening), this did not need any further surgery. Now after 6 months of surgery, he is doing well and happy passing urine from the tip of penis.

About Buccal (oral) mucosa graft urethroplasty:

Buccal mucosa is the lining of the inside of mouth (Cheeks, lips) and is a very suitable tissue to be used for certain specific situations in failed hypospadias surgery. Buccal mucosa urethroplasty is done for those cases where due to previous failed surgeries there is shortage of skin on the underneath of penis and there is no residual prepuce (foreskin). In primary hypospadias (where no surgeries have been done), there is no role or need for using buccal mucosa.

Parents often get alarmed when they are told that we will be using something from mouth for surgery on penis. But since this is a thin layer and the buccal mucosa has excellent regeneration capacity, once we remove a superficial thin layer, the defect doesn’t even need suturing in most cases. The new lining re-appears in 3-4 days’ time and there is no major long-term problem in most cases. Buccal mucosa is hairless and is used to staying wet, hence it is ideal for urethral reconstruction. Like any other graft, once it is taken from mouth and placed on penis – it has to take new blood supply locally. Hence whenever there is a big graft being taken, we wait for 5-6 months before doing the next surgery. In the present case, since the graft was small- we elected to a do the single stage buccal graft urethroplasty with a good result.

About the author:

Dr A.K.Singal is a renowned Pediatric Urosurgeon and one of the best hypospadias surgeons in world and India. Every year, he treats more than 150 kids and adults with primary and failed hypospadias at Hypospadias foundation in Navi Mumbai, India and at Ibn Al Nafees Hospital in Bahrain. Some of these failed hypospadias patients had given up hope for a good result before their referral to Hypospadias Foundation for successful treatment. With the team work 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.

To contact Dr Singal, Submit your enquiry here: http://www.hypospadiasfoundation.com/contact-form-for-patients/

Watch Surgery Video for Failed Hypospadias by Dr Singal

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Posted in Failed & redo Hypospadias,Hypospadias surgeon India,Hypospadias surgery video,Success Stories | Posted by Dr. A K Singal | Posted on January 10, 2019 by Dr. A K Singal | Tagged after hypospadias surgery, best hypospadias hospital, flap repair for hypospadias, hypospadias clinic in india, hypospadias surgeon bhopal, hypospadias surgeon in MP, hypospadias surgeon India, hypospadias surgery india, one stage surgery for hypospadias, onlay flap urethroplasty, onlay island flap hypospadias repair, results of hypospadias, results of scrotal hypospadias surgery, scrotal hypospadias, scrotal hypospadias repair, scrotal hypospadias surgery, severe hypospadias, single stage urethroplasty, urethroplasty for scrotal hypospadias

A child with multiple Failed Hypospadias surgeries finds cure at Hypospadias Foundation with Staged Buccal (oral) mucosa graft urethroplasty

Posted on January 2, 2019 by Dr. A K Singal

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:

  • Buccal (oral) mucosa has excellent healing properties
  • Buccal mucosa is soft elastic and is used to wetness
  • It never grows hair when put inside penis.
  • Buccal mucosa does not get BXO
  • Graft sites heal very fast and child can eat normally in a day or two
  • There is very small chance of any cosmetic deformity as the skin is taken from inside, there is no cut outside the mouth.
  • Like any other graft, once taken from mouth and placed on penis – it takes new blood supply. Hence, it is better to wait for 6 months before doing the next surgery, in cases where a large graft has been taken.

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.

 

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Posted in Failed & redo Hypospadias,Hypospadias surgeon India,Hypospadias surgery video,Success Stories | Posted by Dr. A K Singal | Posted on January 2, 2019 by Dr. A K Singal | Tagged after hypospadias surgery, best hypospadias hospital, flap repair for hypospadias, hypospadias clinic in india, hypospadias surgeon bhopal, hypospadias surgeon in MP, hypospadias surgeon India, hypospadias surgery india, one stage surgery for hypospadias, onlay flap urethroplasty, onlay island flap hypospadias repair, results of hypospadias, results of scrotal hypospadias surgery, scrotal hypospadias, scrotal hypospadias repair, scrotal hypospadias surgery, severe hypospadias, single stage urethroplasty, urethroplasty for scrotal hypospadias

Single stage hypospadias repair surgery video for a child with failed hypospadias: Nagpur to Vellore to Navi Mumbai, India

Posted on July 17, 2015 by Dr. A K Singal

Like every other surgery, hypospadias correction surgery has its own risks, complications and failures. Inspite of the best intentions and efforts of the parents and the treating hypospadias surgeon, still the results may be sub-optimal after the first surgery. Though at the end of hypospadias surgery in OT it may seem that the surgery has gone very well, sometimes there may be minor complications which necessitate a second surgery for hypospadias in some children. The rate of second surgery for a complication or failure of first hypospadias surgery decrease with the expertise and experience of the hypospadias surgeon but it is never zero and that is an important thing for the parents and families to understand.

When the first surgery for hypospadias fails, parents get very disturbed and start looking for more information on why it happened and the solutions and second opinion for hypospadias to help fix the problem. Most of the times, the primary surgeon may be the best person to solve the problem but sometimes the complication may be severe and in such cases the patient should be referred to a centre of excellence in hypospadias surgery.

While minor problems like fistula or cosmetic issues can be treated easily with as second minor surgery- major complications of hypospadias surgery such as urethral breakdown, dehiscence, urethral diverticulum or stricture may require more complicated or even a staged repair with grafts. Hence, the dictum- that first surgery for hypospadias is the best surgery- further surgery if the first one fails is always more difficult and challenging.

At Hypospadias Foundation, we regularly receive kids and adults from all over India and other countries who have had a failed hypospadias surgery elsewhere. Families request for a second opinion for the hypospadias treatment and we advise them comprehensively. Some of these cases really benefit from the specialist care offered by a dedicated hypospadias team.

Case Story

Master A.G., a 3 years old boy, resident of Nagpur, underwent a surgery for a proximal penile hypospadias surgery at a hospital in Vellore. Unfortunately, the healing was not optimal and the whole repair had a breakdown. After 6 months of previous surgery, the family wrote to us and visited us at our centre in Kharghar, Navi Mumbai. On examination, the child has proximal penile meatus with mild chordee. There was a remnant of foreskin (prepuce) on the underside of penis. There was no foreskin left on the topside of penis. We explained to the parents that this may require a two stage repair but we will try out best to make a flap from the residual foreskin and do the surgery in one stage.

Finally after pre-surgery tests and fitness assessments, we took the child for redo-hypospadias surgery. We could make a nice onlay flap out of the foreskin remnant by carefully dissecting the blood supply and preserving the supply to this flap skin. The flap was used to make the new urethra in one stage as it can be seen in the video below.  The surgery took about 3 hours and the child was allowed feeds four hours after surgery. The dressing was removed after 7 days and catheter after 10 days. The hypospadias site healed very well and the child was examined again after 1 month. He was passing urine well in a single stream from the tip of penis. Now, 6 months after hypospadias repair, A.G. continues to do well and his parents are very happy and we are also overjoyed to achieve a good result in this challenging failed hypospadias case. The detailed hypospadias surgery video can be watched by clicking below. Besides the story mentioned here, the video below shows another child story from Raipur, Chattisgarh where the first surgery resulted in a penile torsion and a large fistula. The child underwent a successful single stage surgery at Hypospadias Foundation:

Watch Video of Failed Hypospadias surgery by Dr A.K.Singal

About Hypospadias Foundation

Hypospadias Foundation is an organisation dedicated to care and cure of children and adults suffering from hypospadias and Disorders of Sex development (DSD). Hypospadias is a unique penile urological birth defect and requires complicated and skillful surgery. The results of hypospadias surgery improve with dedication and the number of surgeries a hypospadias surgeon does every year. Besides surgery, a proper selection of the technique and care of the child before and after surgery also matters.

Since its inception in 2008, our dedicated team at Hypospadias Foundation has cared for a large number of children and adults with hypospadias from across India (practically all states) and more than 20 countries. Dr A.K.Singal, Dr Manish Dubey, Dr Rajkumar , Emily Paul, Dr Ajit Baviskar, Naina along with anesthesia team and other staff make sure that every patient with hypospadias receives compassionate care and cure.

Dr A.K.Singal

If you or your loved one has hypospadias and wish to seek an opinion, please write to us at hypospadiasfoundationindia@gmail.com or contact Dr Rajkumar- Coordinator at +91-9821261448 between 10 am-5pm India Time.

You can also fill up this contact form: Contact Hypospadias Foundation

or come to MITR Hospital in person after taking an appointment by sending an email at frontdesk@mitrhospital.com or calling up at +91-22-27743558/ 4229 or +91-9324180553

Watch Video of proximal penile hypospadias correction by Dr A.K.Singal

Watch Video of scrotal hypospadias repair by Dr A.K.Singal

Watch video of Distal penile hypospadias repair by Dr A.K.Singal

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Posted in Failed & redo Hypospadias,Hypospadias surgeon India,Hypospadias surgery video,Success Stories | Posted by Dr. A K Singal | Posted on July 17, 2015 by Dr. A K Singal | Tagged after hypospadias surgery, best hypospadias hospital, flap repair for hypospadias, hypospadias clinic in india, hypospadias surgeon bhopal, hypospadias surgeon in MP, hypospadias surgeon India, hypospadias surgery india, one stage surgery for hypospadias, onlay flap urethroplasty, onlay island flap hypospadias repair, results of hypospadias, results of scrotal hypospadias surgery, scrotal hypospadias, scrotal hypospadias repair, scrotal hypospadias surgery, severe hypospadias, single stage urethroplasty, urethroplasty for scrotal hypospadias

In search for a cure for Hypospadias: From Lucknow to Navi Mumbai, India

Posted on March 4, 2015 by Dr. A K Singal

Hypospadias remains the most common urological anomaly in boys and more than 1 lakh kids are born in India every year with Hypospadias. Majority of these are mild variety like glanular, coronal, distal penile or midpenile hypospadias. Less than 15% of all hypospadias are moderate to severe variety of hypospadias like proximal penile, penoscrotal or scrotal hypospadias. While very mild hypospadias like glanular or coronal without chordee may be left alone without surgery, all other types of hypospadias or those with chordee require hypospadias correction treatment.

There are more than 100 different types of hypospadias surgery techniques described in medical literature attesting to the fact that none of the techniques are perfect or suitable for all types of hypospadias. The hypospadias specialist surgeon needs to be well acquainted with anatomy and various techniques to decide the type of surgery needed in a particular hypospadias case. Subtle variations in anatomy decide the type of technique needed. Hence the decision for each hypospadias is very individualized.

The common techniques in use for primary hypospadias are TIP urethroplasty (Snodgrass repair), Mathieu repair, Onlay Island flap urethroplasty, Prepucial tube and staged Bracka’s urethroplasty. Each technique of hypospadias surgery has its own advantages and disadvantages and case selection becomes very important.

Case: Boy from Lucknow

Master A.C. was born with proximal penile hypospadias in Lucknow. He was advised surgery after one year of age by the doctors in Lucknow. They consulted various surgeons in Lucknow and Delhi but were not satisfied by the approach. Finally, the boy’s uncle who was a scientist in CSIR sent an email to Hypospadias Foundation with all records and pictures asking for an opinion. We advised a clinical examination and a single stage surgery. The family flew to Mumbai and saw us in MITR Hospital, Kharghar where Hypospadias Foundation is located. The penis size for Master A.C. was very small with a stretched penile length of 2 cm and Glans diameter of 11mm. We advised two injections of Testosterone (male hormone) to induce growth of penis at one month interval. After one month of second injection, the glans size increased to 15.5 mm and penis length to 29mm. At this time, we planned a hypospadias correction surgery. A.C. was admitted the morning of surgery and a single stage urethroplasty was done using Onlay Island Flap technique for which Dr Singal is very renowned. The surgery took 90 minutes and the boy was discharged the next morning after hypospadias surgery. The dressing was removed after 5 days and catheter was removed after 10 days. A.C. passed urine well and at one month follow-up was passing urine in a good stream without any issues. The penis has healed very well with an excellent cosmetic result. The parents were overjoyed and sent an email of thanks after one month from Lucknow. Further follow-ups will be via email and phone calls. Patients from across the globe follow-up with us using electronic medium such as email, whats app and skype.

Dr A.K.Singal

Dr Singal with Family from Lucknow

Testosterone (hormone) injection before Hypospadias surgery

In some cases of hypospadias the penile size may be small and the head of penis (glans) may be very tiny. In such cases it is difficult to repair the hypospadias adequately. We advise testosterone injections in dose of 25mg intramuscular injections two months and one month before surgery. The testosterone injections help in two ways: Increasing the size of penis and glans; secondly the blood supply (vascularity) of the foreskin increases which helps in making a good flap in severe hypospadias. Two doses of testosterone injections do not have any short term or long term side effects on body growth etc. Part of the effect of testosterone on penile growth is reversible but part increase in size of penis is permanent. For us at Hypospadias foundation, we give Testosterone injections for babies where the penis size is less than 25mm or the glans diameter is less than 13-14mm.

Onlay Island flap urethroplasty

Onlay island flap urethroplasty is a type of hypospadias repair surgery where a flap is made from foreskin on the top of penis (dorsal prepuce) and brought on underside of penis. This flap is based on a robust blood supply from dartos tissue of the foreskin (see the video below). Onlay island flap urethroplasty is reserved for severe hypospadias or where the TIP repair is not suitable and the chordee is not very severe. In hands of expert hypospadias surgeons, Onlay Island flap urethroplasty offers best results in repair of severe hypospadias. Dr A.K.Singal is one of the best hypospadias surgeon specialists in India for such surgeries. Dr Singal has been invited at various national and international conferences to showcase his surgical technique (see video below). Every year more than 200 children and adults with primary or failed hypospadias are operated under his team’s care in Navi Mumbai, India.

If your child has a hypospadias and you wish to get in touch with Dr Singal for treatment, you can fill up the contact form below or you can see him at one of his hypospadias clinics in Navi Mumbai or Mumbai. You can also call up Dr Rajkumar, Co-ordinator for Hypospadias Foundation at +91-9821261448 between 9am-6pm to discuss any queries.

Dr Singal’s clinics and Timings

Contact form for Dr Singal & Hypospadias Foundation

See Video of Proximal penile hypospadias repair using Onlay Island flap technique- by Dr A.K.Singal

See Scrotal Hypospadias repair using Onlay Island flap urethroplasty- by Dr A.K.Singal

 

 

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Posted in Hypospadias Specialist,Hypospadias surgeon India,Hypospadias surgeon Mumbai,Hypospadias surgery video,Hypsoapdias Surgeon delhi | Posted by Dr. A K Singal | Posted on March 4, 2015 by Dr. A K Singal | Tagged after hypospadias surgery, best hypospadias hospital, flap repair for hypospadias, hypospadias clinic in india, hypospadias surgeon bhopal, hypospadias surgeon in MP, hypospadias surgeon India, hypospadias surgery india, one stage surgery for hypospadias, onlay flap urethroplasty, onlay island flap hypospadias repair, results of hypospadias, results of scrotal hypospadias surgery, scrotal hypospadias, scrotal hypospadias repair, scrotal hypospadias surgery, severe hypospadias, single stage urethroplasty, urethroplasty for scrotal hypospadias

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

Posted on December 4, 2014 by Dr. A K Singal

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

Dr A.K.Singal during Hypospadias surgery

He is available at the following clinics : Clinics and Timings for Dr A.K.Singal

Watch video of Distal penile hypospadias repair surgery video by Dr A.K.Singal

Watch video of Single stage repair surgery of severe hypospadias by Dr A.K.Singal

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

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Posted in About Hypospadias,For Parents and Patients,Hypospadias surgeon India,Hypospadias Surgeon Thane,Hypospadias Surgery,Hypospadias surgery video | Posted by Dr. A K Singal | Posted on December 4, 2014 by Dr. A K Singal | Tagged after hypospadias surgery, best hypospadias hospital, flap repair for hypospadias, hypospadias clinic in india, hypospadias surgeon bhopal, hypospadias surgeon in MP, hypospadias surgeon India, hypospadias surgery india, one stage surgery for hypospadias, onlay flap urethroplasty, onlay island flap hypospadias repair, results of hypospadias, results of scrotal hypospadias surgery, scrotal hypospadias, scrotal hypospadias repair, scrotal hypospadias surgery, severe hypospadias, single stage urethroplasty, urethroplasty for scrotal hypospadias