Author Archives: 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/

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.

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