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2-year male child presented to hypospadias foundation with abnormal position of the penis in relation to the scrotum (penoscrotal transposition). On examination, there was ventral chordee (abnormal curvature of the penis), complete prepuce and complete penoscrotal transposition. Meatus was glanular in position. He was planned for single stage repair of glanular hypospadias, ventral chordee and penoscrotal transposition.

The surgery was started by completely degloving of the penis and assessment of chordee. No chordee was noted after complete degloving. Since the meatus was proximal glanular he underwent distal urethroplasty and glansplasty. Marking was done for penoscrotal transposition correction. Inverted V-shaped incisions were given at the base of both scrotal halves with the midline joining on the ventral aspect at the base of the penis. Both the scrotal halves were dissected deep till the subcutaneous level and rotated to the ventral side and fixed at the base of the penis.

Dressing and catheter were removed on post-operative day 7. Child passed urine well following catheter removal.

Fig 1: Hooded prepuce with complete penoscrotal transposition

Fig 2: Proximal glanular meatus. Marking done on the ventral and dorsal side.

Fig 3: Chordee assessed by artificial erection test and no chordee noted.

Fig 4: Inverted V shaped incision for penoscrotal transposition correction

Fig 5: Scrotal flaps dissected and sutured on the ventral side

Fig 6: Post operative outcome 2 months after surgery

Penoscrotal transposition correction and hypospadias repair in a 2-year-old boy

Penoscrotal transposition (PST) is a rare congenital condition where there is abnormal arrangement of the penis and the scrotum.

There are two main types:

1. Incomplete PST: The penis is located in the middle of the scrotum
2. Complete PST: The penis is positioned below the scrotum, in the perineum.

Penoscrotal transposition is often associated with other congenital abnormalities, including hypospadias, undescended testis, cardiac anomalies, craniofacial deformities, gastrointestinal disorders or intellectual disability.

Minor penoscrotal transposition does not need repair. Complete transposition can be repaired by surgery. The goal of the surgery is to restore the normal anatomical position of the penis and scrotum.

When penoscrotal transposition and hypospadias occur together, it can make the condition more complex and challenging to treat. In minor hypospadias, penoscrotal transposition can be corrected along with hypospadias repair.

In severe hypospadias, we perform the hypospadias repair first and the transposition correction later only if necessary. Penoscrotal transposition correction is done purely for cosmetic reasons. If your child has penoscrotal transposition, then do consult an expert pediatric urologist and take an informed decision before proceeding with the surgery.

About Hypospadias Foundation:

Hypospadias foundation is a centre which provides personalized care for children and adults with hypospadias. It is the best hospital centre in India and world for surgical treatment for hypospadias and its associated conditions. Our dedication in the field of hypospadias has helped us achieve excellent outcomes in these patients. We treat children and adults not only from various parts of India but also from more than 25 countries all over the world. Hypospadias foundation is located at MITR hospital in Kharghar, Navi-Mumbai, Maharashtra, India. Every year more than 200 surgeries of hypospadias are performed at MITR hospital.

Dr A K Singal is an expert and top hypospadias surgeon in India. He is a gifted surgeon and his expertise in this area has helped us achieve excellent outcomes in primary and failed hypospadias in children as well as adults.

Dr Ashwitha Shenoy is an expert pediatric surgeon with special interest in pediatric urology and hypospadias. She holds a particular interest in hypospadias and along with Dr Singal performs advanced surgical techniques for both primary and complex hypospadias cases in children and adults.

Single stage hypospadias repair in an adult, Mr MP, 25 years male presented with difficulty in retracting foreskin. There was no chordee. He was started on steroid cream massage for 2 weeks for the phimosis. Reassessment after 2 weeks showed that we were able to retract the prepuce partially. Partial retraction of the prepuce showed that the MP had a glanular hypospadias with a megameatus variant. He also had spraying of urine and was very concerned about cosmetic appearance of his penis. He was counselled for surgery for hypospadias along with circumcision.

On table examination showed that the patient had a glanular hypospadias with a meatus which was abnormally large, and prepuce was intact. Stay stitch was taken using 4-0 prolene. Circumcoronal marking was done and local anaesthesia with adrenaline was infiltrated at the marked site. Degloving was not done since there was no chordee. Midline incision was given in the dorsal urethral plate and transverse ledge was divided. Glans wings were widely raised and mobilized. Distal urethroplasty was done by continuous sutures using 6-0 PDS over 12 Fr silicone catheter. Local tissues were closed over the urethroplasty using 6-0 PDS. Local dartos flap was raised and sutured over the urethroplasty as a water proofing layer using 6-0 PDS. Glansplasty was done using 5-0 PDS. Glans epithelium was closed using 6-0 PDS. Marked prepucial skin was excised leaving only collar skin and skin was sutured using 6-0 PDS. Sterile dressing was done at end of hypospadias surgery.

Dressing was removed after 7 days and the catheter was removed after 14 days of hypospadias repair. The patient passed urine well and the would healed well with a good cosmetic result. MP was very happy with the overall cosmetic and functional result of hypospadias repair.

Picture 2a &2b: Marking of the incision.

Picture 3a & 3b: Picture showing midline incision in the urethral plate and glans wings mobilization.

Picture 4a & 4b: Distal urethroplasty done and local flap mobilized to suture over the urethroplasty as a waterproofing layer.

Picture 5a &5b: Completion of repair after surgery and operated site assessment at post operative day 14.

Picture 6a & 6b: Cosmetic result at 4 weeks post-surgery

Single stage hypospadias repair in an adult

Hypospadias is a condition in which the urinary opening is on the underside of the penis instead of at the tip. Some of these cases may be missed in childhood. This can happen in:

• Case of mild hypospadias:In mild hypospadias such as present case of glanular hypospadias with MIP variant, the urinary opening may be very close to the tip of the penis. This may not cause any obvious symptoms, and hence may be missed in childhood.
• Presence of complete foreskin:Most of the hypospadias is associated with an incomplete ventral foreskin. Certain types of hypospadias such as glanular hypospadias and MIP variant of hypospadias are known to have complete foreskin. Hence examination of the meatus after retracting the prepuce is necessary in a boy or an adult with suspicion of hypospadias.
• Missed diagnosis:In some cases, diagnosis may be missed if thorough examination is not done in childhood.

Adults need not worry if the diagnosis is missed in childhood. Hypospadias repair can also be done in adulthood successfully. The goals of adult hypospadias repair are as follows:

1. Create a functional urethral opening at the tip of the penis.
2. To straighten the penis to allow for normal sexual function.
3. To improve the cosmetic outcome of the penis

The type of hypospadias surgery depends on the severity of hypospadias, presence of chordee and prior surgical history. An expert hypospadias surgeon will consider all the above factors and take an informed decision and choose the right repair.

About Hypospadias Foundation

Hypospadias Foundation is located at MITR hospital in Kharghar, Navi Mumbai in the state of Maharashtra, India. Every year we get children and adults from all around the country and the world in search of a cure for hypospadias. Our dedication, determination, and perseverance in the field of hypospadias has helped us achieve excellent outcomes.

Dr A K Singal is a top and expert surgeon who has dedicated his life in treating children and adults with hypospadias. His expertise in this area has helped us achieve excellent outcomes in adults and children with hypospadias.

Dr Ashwitha Shenoy is an expert pediatric urologist with special interest in pediatric urology and hypospadias. Both Dr Singal and Dr Shenoy work together to give best results for hypospadias surgery in India for both children and adults.

Contacting the Hypospadias Foundation:

• Email: hypospadiasfoundationindia@gmail.com
• Phone for appointment or Teleconsult with Dr Singal/ Dr Shenoy:

• • +916262840940
  • +916262690790

+919324180553 (whatsapp and teleconsult

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Adult Redo Hypospadias repair, MM, a 35-year male, from Bangladesh a case of failed hypospadias who underwent three hypospadias surgeries in the past but did not get the desired result due to complications of hypospadias repair. He presented to us with complaints of passing urine from two sites – coronal and proximal penile region.

On clinical examination in the OPD, we found that the meatus was located at the coronal region. There was large urethral fistula at the proximal penile region with hair growth from the site of fistula. He was planned for cystoscopy to assess for the status of the urethra and redo hypospadias surgery in a single stage or in two staged was to be decided based on the results of cystoscopy.

1. Clinical picture showing coronal meatus and proximal penile fistula.

Cystoscopy showed 1cm of hairy urethra at the site of proximal penile fistula, the rest of the proximal urethra was normal. Since majority of the urethra was normal, we planned for single stage repair. We chose to proceed with single stage proximal and distal oral mucosa inlay graft urethroplasty.

2. Cystoscopy picture showing hairy urethra

Patient did not have chordee hence degloving was not done. Midline incision was given over the urethral plate in the glans and distal penile region to assess the quality of the urethral plate. The urethral plate was healthy with no signs of scarring. Proximal hair bearing unhealthy urethra was excised completely. Since urethral bed was found to be healthy in the proximal and distal region, we planned to place an oral mucosa inlay graft at both sites and proceed with single stage urethroplasty.

Oral mucosa graft was harvested from the right cheek. The graft was defatted and sutured at the urethral bed distally and proximally. The graft was sutured at the edges of the urethral plate and was quilted in place using 6-0 PDS and 5-0 PDS sutures. Following inlay graft placement, proximal urethroplasty was done using 5-0 vicryl stitch, first layer was continuous subcuticular inverting sutures. Second layer closed using local tissues with 5-0 vicryl. Glans wings were widely mobilized and distal urethroplasty along with Glansplasty was done using 5-0 vicryl.

Patient had a per urethral catheter and suprapubic cystostomy (SPC) after redo hypospadias surgery. Dressing change was done on post operative day 4 and dressing change was done on every 4^th day. Per urethral catheter was removed on post operative day 21 and SPC was removed on post operative day 22.

3. a & b Picture shows incision in the distal urethral plate and proximal urethra

4. a & b Picture showing oral mucosa graft, it has been placed and quilted in the distal and proximal urethral bed

5. a & b: Distal urethroplasty being completed and second picture showing completion of repair both proximal and distal repair

6. Picture showing status at post operative day 15 and second picture shows urine stream after catheter removal.

Patient had a per urethral catheter and suprapubic cystostomy (SPC) after surgery. Dressing change was done on post operative day 4 and dressing change was done on every 4^th day. Per urethral catheter was removed on post operative day 21 and SPC was removed on post operative day 22.

Post catheter removal the patient was passing urine in single straight stream with no leak. Patient was started on meatal dilatation using meatal dilator with mild steroid ointment for 3 months.

Redo hypospadias in an adult after previous multiple failed hypospadias surgeries  

Hypospadias is commonly diagnosed in childhood, but adults also present with hypospadias because either they were never operated in childhood, or they have complications after multiple hypospadias surgeries in childhood. The common complaints which they present with are poor stream, urinary tract infections, spraying of urine, difficult sexual intercourse, or infertility. The common findings which we find in adults post failed hypospadias repair are hairy urethra, residual chordee, urethral diverticulum or urethral stricture. Most of the adults with these complications will need a redo surgery in either single or multiple stages. In more than 95% of the surgeries, we need to use oral mucosa graft while reconstructing the urethra. It is used either as an inlay graft or in staged repair.

Cystoscopy is the first step in any of these redo hypospadias repairs. Through cystoscopy we will get an idea about the native urethra, presence of any urethral stricture or diverticulum, any hair in the urethra and the diverticulum at the prostatic urethra. This information will help us decide if we can plan a single staged repair or need for a two-stage repair.

In the presence of long segment unhealthy urethra, we may need to plan a staged repair. The unhealthy urethra must be completely removed, and oral mucosa graft should be placed on the urethral bed in first stage and in second stage the urethra is reconstructed from the graft. The second stage is planned when the oral graft over the penis becomes soft like lip and can be easily rolled to form a urethra. The duration between the two stages is somewhere between 6-9 months. If there is short segment of urethra which needs to be replaced, then it can be done in single stage by placing an oral mucosa inlay graft.

The healing in adults after hypospadias repair is slow as compared to children hence per urethral catheter is kept for a longer time which is around 21-28 days. Suprapubic cystostomy is done in every adult undergoing hypospadias urethroplasty. This helps in decreasing the stress on our urethroplasty suture line which in turn contributes to better healing.

About Hypospadias foundation

At hypospadias foundation, we get adults and children from all over the world in search of treatment for hypospadias. We provide support and information for children, adults and their families affected by hypospadias. Dr Singal and Dr Shenoy are deeply devoted to creating awareness and helping patients get the right treatment for hypospadias be it primary, redo or adult hypospadias. Children and adults from more than 25 countries visit our hypospadias foundation in search for cure and are cured of hypospadias.

Dr A K Singal is a highly experienced surgeon and regarded as the best hypospadias surgeon in India and in the world. He has dedicated his life towards treating children and adults with hypospadias. His expertise in this area has helped us achieve excellent outcomes in adults and children with hypospadias.

Dr Ashwitha Shenoy is an expert pediatric surgeon with special interest in pediatric urology and hypospadias. Both Dr Singal and Dr Shenoy work together to give best results for hypospadias surgery in India for both children and adults.

Contact us:

For 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

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