N.S., a one year old child was brought to Hypospadias Foundation with one failed primary hypospadias surgery which done at a hospital in Mulund, Mumbai. The child had undergone a Snodgrass urethroplasty with preputioplasty (prepuce preserving hypospadias repair) for a distal penile hypospadias. After removal of the catheter, the parents had noticed this stream and leakage of urine from the underside of penis at the site of previous opening.
Notice the narrow urinary opening and a urethral fistula still present in distal penile region after surgery done elsewhere.
Notice the bend of the penis downwards suggestive of chordee
They had rushed to us 2 weeks after surgery as the child was having a lot of pain while passing urine. On examination the child has swelling of the penis with local infection. We started the child on oral antibiotics and pain killers along with warm tub baths. Once the infection subsided, we did a check cystoscopy to make sure that the distal passage was ok. Parents were taught calibration with a feeding tube twice a week to check distal urethral passage. After 6 months, the child was taken up for reoperative hypospadias repair with correction of chordee which was still present (pic 1 & 2)
At examination on the table, there was a large fistula in the distal penisleregion and due to misalignment of new urethra because of previous surgery- we could not pass catheter easily into the bladder (pic3).
During surgery, catheter passed from tip exited through the fistula in mid penile region. The distal and proximal urethra were not aligned
Incisions are marked for failed hypospadias repair by a round incision at urethral fistula site and also a incision to deglove the penis to release the chordee
After degloving of the penis, fistula can be clearly seen
Incisions for the first step- degloving of the penis were marked (pic4). The penis was degloved (skin was taken down) and all the fibrous scarred bands were released to straighten the penis (chordee correction)- pic5. An artificial erection test was done to confirmed that the penis was absolutely straight without any chordee (pic 6). The urethral fistula closure was performed in multiple layers with 6-0 PDS stitch (pic7). Finally the excess prepuce was excised and a good cosmetic outcome and look like a circumcised penis was ensured. The catheter was left inside for 3 days.
No chordee (bend of penis) seen after degloving and release of bands
Urethral fistula closed in 2 layers with absorbable PDS sutures
Completed Redo-Hypospadias surgery with excellent cosmetic result
6 months later, the child is passing urine well in a nice thick stream and the penis looks like just a circumcised penis.