Dr. A.K.Singal, Author at Hypospadias Foundation

June 06 2024

Safe and Effective Anesthesia for Hypospadias Repair Surgery in Children

Hypospadias surgery is a procedure to correct the opening of the urethra on the underside of the penis. It is one of the most common pediatric urological surgeries. Ensuring your child’s safety and comfort throughout the surgery is paramount. Anesthesia plays a crucial role in achieving this goal.

Types of Anesthesia for Hypospadias Surgery:

 General Anesthesia: The most common approach, general anesthesia renders your child unconscious and pain-free. Medications are typically
administered intravenously (through an IV) or via inhalation through a breathing mask. The anaesthesia is usually short and there is no significant
effect on the child.

 Regional Anesthesia: Regional anaesthesia is one which works only in the specific area of the body. The regional anaesthesia used in hypospadias
repair is a caudal block, an injection near the tailbone for targeted pain control. This caudal block gives good pain relief for six to eight hours and
sometimes even up to ten hours after hypospadias surgery. Older children may feel tingly and numb in the lower limbs and may find it difficult to walk till it wears off, usually within first 12 hours

 Combined Anesthesia: Combining general and regional anesthesia offers the benefits of both: comprehensive pain management during surgery and a smoother recovery from general anesthesia.

The anaesthesia medicines chosen in children is such that there are minimal side effects and, we can resume oral intake as early as 1-2 hours after the hypospadias correction surgery.

Pediatric Anesthesiologists:

Anesthesia for hypospadias surgery is administered by a trained pediatric anesthesiologist, a medical doctor specializing in anaesthesia for infants and children and takes good care before, during, and after hypospadias repair surgery. They will meticulously assess your child’s health before hypospadias surgery, discuss anesthesia options, and choose the safest and most suitable approach for your child’s individual needs.

Communicate and Ask Questions:

Open communication with your child’s hypospadias surgeon & urologist and anesthesiologist is vital. Don’t hesitate to ask questions regarding the anesthesia plan and any concerns you may have. Feeling informed and involved in your child’s care can significantly ease anxieties.

At Hypospadias foundation, we have trained pediatric anesthesiologists who have managed more than thousands hypospadias correction repairs. From airway management, right medications to post operative pain relief we believe in a complete care of the child from pre surgery to post surgery. Safe and effective anaesthesia is necessary for good post operative recovery after hypospadias surgery.

Effective Pain Relief After Hypospadias Surgery

Pain relief is very important especially in a child because a cranky child makes the parents and the hypospadias surgeon anxious. After any procedure, it’s natural for your child to experience some discomfort but the discomfort should be manageable. Here’s a guide to effective pain relief after hypospadias surgery:

Doctor-Prescribed Medications:

 Pain relievers: After surgery we prescribe pain medications, often starting with acetaminophen(paracetamol) or ibuprofen. The medicines must be given as advised because good pain relief means a comfortable child and in turn leads to good healing after hypospadias repair.

 Antibiotics: To prevent infection, antibiotics are prescribed after hypospadias surgery. They must be continued till the catheter removal and
sometimes for a few days even after the hypospadias catheter is removed. Infection can destroy the entire hypospadias repair hence we need to be
vigilant and avoid infection at all costs.

 Bladder antispasmodics: The presence of a urinary tube can cause urinary bladder contractions. The only way to manage this is by prescribing anti spasmodic medicines. Hence after hypospadias surgery till the catheter removal, the child will be on anti-spasmodic medicines.

 Pain due to erection: Painful erections after hypospadias surgery occur in every child and are even more prominent in teenagers and adults. This pain can be quite bad due to swelling of penis and the presence of a urinary tube. Hence we prescribe a stronger painkiller diclofenac in the form of
suppository during these episodes of severe pain. This medicine gives good pain relief in times of extreme pain. For adults we also add more medicine to decrease painful erections at night.

At-Home Pain Management Strategies:

 Positioning: Encourage your child to rest comfortably, positioning themselves to minimize tension on the surgical area. This can be lateral or
supine position with pillow support.

 Distraction: Engaging your child in their favourite activities or games can help take their mind off any discomfort after hypospadias surgery

 Loose Clothing: Tight clothing can apply pressure on the operated site and cause discomfort to the child. Opt for loose-fitting clothing made from
breathable fabrics to avoid irritation.

 Dietary Adjustments: Prefer healthy nutritious food over processed food. Processed food does not have fibre and cause constipation in a child which in turn can cause bleeding at the operated site during straining. Maintaining hydration is also essential to prevent constipation.

 Hygiene: Maintain proper hygiene around the hypospadias surgical site as instructed by your doctor. Change inner diaper frequently when dirty and be vigilant for soling of dressing. If dressing gets dirty at any point, do visit the hospital and get a hypospadias dressing change.

 Activity Restrictions: Follow the doctor’s recommendations regarding activity levels to promote healing and prevent complications. Any vigorous
activities are generally avoided typically for 4-6 weeks after hypospadias surgery. Children can play at home and other board games comfortably.

Remember:

 Consult your Hypospadias Doctor: If pain seems excessive or worsens, consult your child’s doctor for further evaluation and possible medication
adjustments.

 Be Patient: Healing takes time after a hypospadias surgery. Be patient with your child and offer support throughout the recovery process.

At Hypospadias Foundation India, we have treated thousands of children and adults with hypospadias. Our approach to hypospadias repair includes
comprehensive care from preoperative to post operative period. Remember, every child heals at their own pace. By being prepared, informed, and supportive, you can help your child through this journey and ensure a successful recovery. Dr A.K.Singal and Dr Ashwitha Shenoy are rated as the best hypospadias surgeons in India. Their experience in the field of hypospadias makes them the best surgeons for hypospadias repair for both children and adults. If you need an opinion or consult us for your child, please do write to us at hypospadiasfoundationindia@gmail.com or fill up this contact form or visit us at the hospital.

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May 05 2024

What is urethrocutaneous fistula after hypospadias repair and why does it occur?

Hypospadias is a condition seen in 1 in 150 to 200 newborn boys. Surgical repair is the primary treatment for hypospadias, aiming to reposition the urethral opening to the tip of the penis, straighten any abnormal curvature and to improve the overall appearance of the penis. Like any other surgery, complications can occur even after hypospadias repair. The common complications which occur are urethrocutaneous fistula, meatal stenosis, glans dehiscence and rarely, urethral diverticulum or urethral stricture. Among these, the most common and notorious complication is the urethral fistula.

Urethrocutaneous fistula refers to the development of an abnormal opening between a newly constructed urethra and the skin on the underside of the penis. When this occurs, the child or the adult will have more than one urine stream. There will be one stream from the tip of the penis (the newly created opening) and the other stream or leak of urine from the fistula site. The leaking of urine from the fistula site tends to fall on the legs or can wet the clothing, causing inconvenience to the children and the adults. In our centre, we see a lot of children coming for urethral fistula treatment after the first surgery somewhere else, like the case below.

Post hypospadias surgery fistula can occur due to multiple reasons. Some of them are as follows:

Intraoperative factors:

Poor blood supply: Poor blood supply also called as ischemia is one of the most common factors that can severely impair and delay tissue healing. The process of wound healing is complex and heavily relies on the continuous supply of essential nutrients along with oxygen via the blood stream. During urethroplasty if the blood supply of the tissues is poor then fistula formation can occur post-surgery due to poor healing.
Inadequate tissue closure: During urethroplasty, we must take care that there should be a watertight closure of the newly reconstructed passage. And this urethral passage should be reinforced with multiple layers of tissues such as local tissues or dartos flap so that the risk of fistula formation decreases. Gaps in the urethral closure with deficient overlying tissue layers can increase the risk of fistula formation.
Tight closure of tissues: The urethroplasty and overlying tissue closure in hypospadias should never be under tension. If the tissue closure is tight then the vascularity is affected and can cause ischaemia of the tissues leading to skin necrosis and fistula formation.
Narrow or stenosed urethra: The newly reconstructed urethra in hypospadias should be of good calibre. If the urethra becomes narrow, then there can be increased pressure within the urethra proximal to the narrow segment leading to a weaker point which gives away causing urine leaking from this point which becomes a fistula.
Type and severity of hypospadias: Severe hypospadias or complex hypospadias is usually associated with severe penile curvature along with urinary opening situated far from the head of the penis. Longer urethral reconstruction is inherently more complex with higher risk of complications and hence higher chance of fistula formation compared to milder forms of hypospadias.
Fibrotic or unhealthy tissues: Fibrotic tissues are associated with poor blood supply and using such tissues for urethral reconstruction can be disastrous with higher possibility of dehiscence and fistula formation.
Surgeon experience: The risk of fistula formation will be higher at a centre performing very few hypospadias repairs compared to a centre performing more than 50-60 repairs every year. The technique, tissue handling etc gets better only once the surgeon performs more than 50 hypospadias surgeries every year.

Post operative factors:

Infection: If the operated hypospadias site gets infected in the post-surgery period, then there is a possibility of dehiscence at the site of infection which in turn can cause fistula formation.
Poor nutrition: Optimal nutrition is not just beneficial but fundamental for wound healing. Deficiency in key nutrients can cripple the body’s ability to repair itself leading to weakened tissue, increased infection risk and ultimately wound breakdown and higher chance of fistula formation
Presence of constipation: Constipation can indirectly contribute to wound breakdown. Straining to pass stool can put pressure on the penile area and can put undue stress on the delicate tissues and new sutures which can give away and cause fistula formation.

Inspite of the best efforts of the hypospadias surgeon, fistula can occur after hypospadias repair. Even if fistula occurs, there is a possibility that the fistula can close spontaneously. At Hypospadias Foundation, we wait for 6 months to assess the same and if it does not close then surgery in the form of fistula closure may be required. Before urethral fistula closure it is mandatory to check the urinary passage beyond the site of fistula. If the passage beyond the site of fistula is narrow, then simple urethral fistula closure may not suffice, and reconstruction of the entire distal passage (distal urethroplasty) may be necessary.

Hypospadias Foundation is a centre located in Kharghar, Navi Mumbai, Maharashtra, India, with surgeons having expertise in hypospadias repair in children and adults. We regularly manage both primary hypospadias repairs and complex cases, including those with previous multiple failed repairs. A significant focus of our patient base consists of children and adults who have had failed hypospadias surgeries elsewhere, including persistent fistulas. Our approach involves not just good surgical technique but also diligent pre-operative assessment, focussed post-surgery care and critical decision making for good long-term outcomes.

Dr A.K. Singal is the founder and head of Hypospadias Foundation, India. He is considered the best hypospadias surgeon in India and the world and has successfully treated more than thousands of children and adults with hypospadias with excellent results.

Dr Ashwitha Shenoy is an expert hypospadias surgeon with a special interest in the field of hypospadias and pediatric urology. Both Dr Singal and Dr Shenoy strive to achieve excellent outcomes in adults and children with hypospadias. Our success rate at Hypospadias Foundation for all types of repairs, including complex and failed repairs, is more than 95%.

For an appointment, kindly contact us at the contact details given below.

MITR hospital & Hypospadias Foundation, Kharghar, Navi Mumbai, India – Tue/Saturday 4:00pm-6:00pm, Call for appointments: +91-9324180553. Or email us at hypospadiasfoundationindia@gmail.com

If you wish to contact us, pls fill up this form- Contact form for Hypospadias Foundation

or pls call up our clinic for an appointment- Clinic details for Hypospadias Foundation.

May 05 2024

What are the factors influencing success of hypospadias surgery?

Successful hypospadias surgery is a corrective procedure that aims to create a urinary passage with opening at the tip of the penis. The final cosmetic result is such that the child or adult can pass urine in a single straight stream without any pain or discomfort. Any curvature of the penis (chordee) is also corrected during the hypospadias surgery, and this is important for future sexual function.

Most boys who undergo hypospadias repair in early childhood before 5 years have minimal recollection of hospital stay and surgery. The repairs are typically durable and hold up well throughout puberty and adulthood. The success rates vary depending on the severity of the condition, but most studies report a success rate of over 90% for distal hypospadias (mild cases) and 80% for more proximal cases. At hypospadias foundation, we are dedicated in treating children and adults with hypospadias for last 15 years, hence our success rates are more than 95% for mild, severe and redo hypospadias in children and in adults making us a leading centre for hypospadias repair in India and worldwide. Here are some factors that contribute to a successful hypospadias surgery:

Surgeon’s experience : Hypospadias surgery is a specialized procedure, and the success rate is higher when surgery is performed by a surgeon who has experience with this type of surgery. A skilled surgeon with experience in hypospadias repair can create a more natural-looking penis, which can boost your child’s confidence and self-esteem in the long run. Hence a surgeon who performs more than 50 surgeries per year has better success compared to centres which perform only very few per year. At hypospadias foundation we currently perform almost 250 hypospadias correction surgeries every year.
Severity of hypospadias: Generally, milder forms of hypospadias have a higher success rate than more severe forms. Severe hypospadias is usually associated with moderate to severe chordee and mostly needs a staged repair. The risk of complications is also higher in severe hypospadias.
Age at surgery: Hypospadias surgery is typically performed between 6 to 18 months of age or between 3-5 years of age. The results after hypospadias surgeries are excellent in childhood and it also ensures proper development of the penis. Surgery in adulthood is associated with slow healing due to decreased collagen production and decreased cell turnover with age which in turn leads to higher risk of complications. Rate of infections and breakdown is also more in adult hypospadias repairs.
General health of the child: We routinely check hemoglobin, overall growth & wellness of the child, urine for any infection before surgery. Children who are underweight, not growing well, have added anomalies or feeding issues, have higher rates of complications.

During and following hypospadias repair surgery, there are several things that can be done to improve the chances of a successful outcome :

During the surgery :

Choosing the right technique: There are several different surgical techniques used to repair hypospadias. The best technique for a particular child or adult will depend on the severity of the hypospadias and the surgeon’s experience. A hypospadias surgeon should choose the best technique after considering all the factors during the surgery. With more experience, a skilled surgeon can choose a technique which will give good results in a particular case. Experience allows surgeons to anticipate potential problems during surgery and adapt their approach accordingly. They can recognize anatomical variations and make real-time decisions to avoid complications.
Tissue handling: Most of the good results in hypospadias surgeries are attributed to use of right instruments, technique and how gently the surgeon handles the tissues. A skilled surgeon handling a hypospadias surgery translates to better handling of tissues, minimizing blood loss, and precise suturing, all reducing potential complications.

Minimizing the duration of surgery: The longer the duration of surgery the higher the risk of tissue edema and impaired healing. The tourniquet is tied at the base of the penis for some steps to avoid bleeding during the surgery. If the tourniquet time is longer than 30 minutes, then there may be risk of tissue injury and healing may be slower in these cases.
Breathable dressing after surgery: Tight compression dressing can cause pressure on the new urinary passage hence light dressing is advised after hypospadias surgery.
Preventing infection: All aseptic technique and precautions should be followed during the surgery to prevent surgical site infection. Also, a pre-surgery antibiotic should be given to prevent infections.

After surgery :

Dressing care: Hypospadias dressing can get soiled with stools after surgery. Whenever hypospadias dressing gets dirty it must be changed. Soiled dressing is a nidus for infection. Parents must be strictly instructed to keep a close watch and report to the hospital in case of soiled dressing.
Identifying infection at early stages: Fever with foul smelling dressing or pus discharge from within the dressing are signs of wound infection. When present, the dressing must be changed immediately along with administration of intravenous antibiotics to control the infection.
Using prescribed medications as directed: Your doctor will prescribe medicines such as oral antibiotics, analgesics, anti spasmodics, multivitamins etc which will prevent infection at the operated site, give relief from post operative pain and help in healing.
Wound care after dressing and catheter removal: After dressing and catheter removal, hot water bath is advised three times a day. Local antibiotic ointment is applied at the operated site to facilitate healing. Failing to follow these may lead to infection at the operated site, in turn affecting the surgical results.
Feeding & general health: Make sure that the child is taking a nutritious diet, is pain free and happy in the recovery phase. Junk food should be avoided. Constipation should also be prevented by good hydration, fibre rich foods and if need be laxative syrups.

Experienced surgeons would have likely encountered various complications of hypospadias before. This knowledge allows them to identify early warning signs and take corrective measures swiftly, minimizing the severity of complications.

If you are considering hypospadias surgery for your child, it is important to discuss the risks and benefits with a hypospadias specialist. Best hypospadias surgeon is the one who has abundant experience in this field and have likely interacted with many families dealing with hypospadias. This experience allows him/ her to communicate complex medical information clearly and answer your questions patiently, easing your anxieties. An experienced surgeon doesn’t guarantee zero complications, but using proper protocols significantly reduces the risk. Open communication is the key. Discuss your concerns about complications with the surgeon and ask questions openly. By finding a skilled and experienced hypospadias surgeon and openly discussing potential complications, you can ensure best outcome for your child’s hypospadias surgery.

If you are looking for a centre with excellence in hypospadias and dedicated in hypospadias treatment and care, then hypospadias foundation at Kharghar, Navi Mumbai would be one of the choices. We at hypospadias foundation specialize in hypospadias surgery, including complex and redo cases. We recognise the emotional impact of hypospadias and offer counselling support for families. If your child or someone you know is suffering from hypospadias, then do write to us or visit us so that we can help you get the best hypospadias treatment.

Contacting the Hypospadias Foundation:

Website: https://www.hypospadiasfoundation.com/
Email: hypospadiasfoundationindia@gmail.com
Phone:
- +916262840940
- +916262690790
- +919324180553( whatsapp and teleconsult )

Fill up contact form: https://www.hypospadiasfoundation.com/contact/

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April 04 2024

Recovery after hypospadias repair surgery

One of the common questions which the parents ask in clinic when we counsel them for surgery on hypospadias is “how many days will it take for my kid to recover after hypospadias repair surgery.” Understanding the recovery process after hypospadias repair surgery is crucial for parents and caregivers. This comprehensive guide provides insights into postoperative care and tips for managing the recovery journey effectively.

And our answer as expert Pediatric Urologist & Hypospadiologist, though very detailed, could be read two ways.

One, we are avoiding a straightforward answer and the second may be that we want to give a deeper and more enriching answer which clears all the doubts and answers the question in its whole entirety.

The recovery can be discussed along many dimensions:

The immediate and the most concerning is the Recovery from anesthesia and this usually occurs within 2-3 hours after surgery implying that the kid will be able to talk, converse and start taking liquids etc after hypospadias surgery. Usually after 4hours of surgery kids can take solid foods and normal diet. We have made sure that our operation theatre, surgical and anaesthesia protocols are child friendly to make sure that the recovery is fast, and kids go home fast. The anesthesia used is caudal plus sedation in most cases which allows for pain free recovery post hypospadias repair. We also keep a warming mat under the child during surgery to prevent low body temperature, the anesthesia team is trained in managing small babies, and all the equipment for anesthesia and surgery is baby friendly.

Recovery after hypospadias repair surgery

Pic 1: Dressing immediately after surgery.Recovery to playing and walking usually happens by evening of hypospadias surgery and often we find kids fully comfortable and running around on the same day by evening or by the morning of day after surgery. That’s also the reason why we moved from bulky dressings and bags- avoiding these and using a double diaper method of managing kids after surgery allows them full freedom of movement. It is during this phase that all the hospital staff at MITR Hospital make sure that the child is well cared for and parents are made comfortable during the stay.Recovery from dressings & catheter takes more time. After hypospadias surgery, dressing is usually changed after 7 days and catheter after 7-14 days, depending upon the complexity of hypospadias repair. In some distal hypospadias we remove the dressings and catheter at the same time which is at first follow up visit one week of surgery. This saves unnecessary visits to the hospital. The overall intent is to make hospital visits for the kids as less as possible. For adult hypospadias repair, catheter may need to be kept as long as 3 weeks.

Pic 2: Hypospadias surgery site inspection at week 1 after surgery

Pic 3: Hypospadias surgery site inspection at week 3 after surgeryRecovery to a new urethra in the larger sense of passing urine through the new passage happens when the child starts passing urine comfortably which can be expected 2-3 days after removal of the hypospadias catheter. For the first two or three days there may be little bit of pain in passing urine through the newly formed urethra.The final recovery happens when the swelling of the penis subsides, the sutures get absorbed and the penis assumes its final shape and thus one can see the cosmetic outcome. This time which the swelling takes to go away may be variable but usually takes up to a month after hypospadias surgery. Especially in kids after hypospadias surgery or urethroplasty, sometimes the penis looks black, blue, swollen and bruised and yet after a month or so everything looks so normal as if just a circumcision has been done.
Penis is an organ which tends to swell up at the slightest excuse be it a minor infection, injury and as hypospadias surgery involved major cutting and stitching, penis does swell up significantly after hypospadias surgery. Equally importantly the penis is also an organ which heals very fast. Hence, almost normal skin cover comes back even after an extensive hypospadias repair in which a lot of penile skin gets rearranged. Sometimes the penile skin looks very raw and incomplete for some days after surgery but when the patients finally come back after a month it looks like no surgery was done as the skin of penis has an amazing regenerative capacity. Partly this is because of an extensive blood supply of penis skin and partly because of the loose specialized skin.

We have started using specialized Tegaderm and light gauze dressings.

Tegaderm is a transparent cling wrap kind of dressing which is very easy to take off and gauze piece is made of soft cotton which is rolled around penis for 3-4 turns and then held with a micropore tape. One more throw of the tape also helps in holding the catheter in place after surgery. These tapes are easy to take off in outpatient clinic mostly by junior staff. The catheter is held by a small fine stitch to the glans, and this can be easily cut in outpatient clinic to remove the catheter.

The hypospadias dressing which we do at our centre does not impair the blood supply as the pressure exerted by such dressing on an already swollen penis is quite less. Also, a loose dressing decreases the chances of pain especially when erection happens at night. Our dressings also allow tissues to breathe and have good circulation after urethroplasty.

At hypospadias foundation, every year we treat more than 250 children and adults with hypospadias. Children and adults from more than 25 countries visit our hypospadias foundation center in search of cure for hypospadias. Very few centers all over the world have achieved excellence in hypospadias and we are one among them. We are dedicated in treating hypospadias and want to help kids and children suffering from hypospadias.

Dr. A.K. Singal is a renowned and top Pediatric Urologist practicing in Navi Mumbai. Dr. Singal’s passion and expertise in Hypospadias led him to establish the hypospadias foundation in 2006. The Hypospadias Foundation is the World’s First and India’s only hospital dedicated to caring for children and adults with hypospadias. It is considered as the best hospital for hypospadias surgery in India.

Dr Shenoy along with Dr Singal aim to provide world class surgery and treatment for children and adults with hypospadias and DSD. They have helped more than thousands of children and adults with hypospadias from all over the world.

If you or your child has hypospadias and you wish contact Hypospadias foundation, the you can contact us by following methods:

Contacting the Hypospadias Foundation:
- Website: https://www.hypospadiasfoundation.com/
- Email: hypospadiasfoundationindia@gmail.com
- Phone:
  - +916262840940
  - +916262690790
  - +919324180553(whatsapp and teleconsult)
Fill up contact form: https://www.hypospadiasfoundation.com/contact/

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Contact Form for Hypospadias Foundation

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Contact Form for Hypospadias Foundation