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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Master V.W., a 14-year-old boy, was referred to us from Jalgaon, with a history of multiple failed surgeries. At presentation, he had a penscrotal hypospadias for which he underwent a two-stage urethroplasty at one year of age at one of the medical colleges in Mumbai. Due to complications, he needed three further surgeries including bladder mucosa grafting, buccal mucosa grafting, and then urethroplasty, which all failed. Finally, at the age of 5 years, a perineal urethrostomy was performed, and all hope of surgical corrections was abandoned. Now, a 14-year-old boy with Hypospadias Cripple Staged reconstruction is being considered.

His family and relatives did not lose hope and asked their local doctor to search for any possibility of repair after a few years and they found out about Hypospadias Foundation on internet. They finally reached us and at examination he still had severe hypospadias with penoscrotal transposition. There were multiple scars on the belly due to previous surgeries (pic1). He was passing urine through a perineal urethrostomy (artificial opening made in front of anus)- see pic 2. His penis still had chordee (bend).

We planned to do the major corrective surgery in two stages. We took up VW for first stage surgery  which included the following

• Cystoscopy and ascertaining usable urethral passage
• Excision of all scar tissue on underside of penis
• Straightening the penis – chordee correction
• Closing the perineal urethrostomy and establishing a penoscrotal meatus (pic3)
• Correcting the penoscrotal transposition (pic4)
• Left orchiopexy was needed as the left testis was caught in the fibrosis
• Buccal mucosa graft (pic 5)

After full healing of the buccal mucosa graft (pic6), after 4 months, we did the second stage surgery – tubularisation of the buccal graft into a nice wide bore urethra (7).

For proper healing, we did a second stage neourethral coverage with a Tunica Vaginalis flap from right testis (pic8). Tunica Vaginalis is a thin membrane which surrounds the testis and has excellent blood supply and healing properties. It is often used as a second layer insurance cover in difficult or complex hypospadias repairs as in the present case (pic9).

Finally, we did a glansplasty to bring the urinary opening to almost the tip of penis (10). The final outcome was very good as the child had a straight penis, testis in normal location below the penis and a normal urinary opening with normal urine passage.

AKM, a 10-year-old boy with penoscrotal hypospadias, had undergone two-stage hypospadias surgery at a hospital in Mumbai at the ages of 4 and 6 years. He developed difficulty in passing urine and had a lot of pain while doing so. The urine stream was also narrow after hypospadias surgery. He came with fever and pus in urine, experiencing extreme pain during urination. Staged Buccal (oral) Graft Surgery repair.

He was referred to Dr A.K.Singal, Pediatric Urologist and Hypospadias surgeon in emergency. We admitted the child at MITR hospital and started IV antibiotics as he had urinary infection. He was taken up for surgery two days later. The whole urethra was found to be narrow till bulbar urethra. We laid open the urethra till bulb of urethra deep in scrotum. The urethra from glans to penoscrotal region was excised. In the urethra from penoscrotal region to the bulb was augmented with a dorsal inlay oral mucosal graft taken from the cheek and primary closure was achieved till penoscrotal junction. Labial oral graft was harvested from the lip and whole ventral surface of penis was grafted with oral mucosa. The child was discharged two days later, and dressing and catheter was removed 7 days later. He did very well, and the graft healed well. Six months later, urethroplasty was completed from the penoscrotal junction till glans. Glansplasty was also done to complete the penile repair. Catheter was removed 6 months later. AKM has completed 4 years after surgery and now is passing urine well standing up like a normal boy and in good stream without any complications. The follow-up[ uroflowmetry studies have shown good outcome and good urine flow. The family is extremely happy to see good result in hands of expert surgeon.

A 5 years old boy was referred to Hypospadias Foundation after two previous failed surgeries. The child had complications of previous hypospadias surgeries such as distal open area due to dehiscence, distal meatus, chordee (bend of penis) and a thin glans bridge. A 5 years old child failed hypospadias repair.

As a first step, the penis was degloved and chordee checked. There was still significant bending of the head of the penis (pic 2). Chordee correction: Chordee was corrected by Tunical Albuginea plication at 12 o’clock on the upper side of penis and there was no chordee on rechecking the penis (pic3). An onlay flap was harvested from dorsal penile skin with very good dartos blood supply for urethroplasty (pic4). The flap was rotated around the side of penis and brought to underside of penis for urethroplasty (pic5). The urethroplasty was finished uneventfully but there was severe skin shortage on the underside of penis due to two previous surgeries. Multiple z plasties were done to mobilize and stretch the skin for covering the underside of penis (pic6). A 5 years old child failed hypospadias repair.

Catheter was left in place for ten days for healing. After removal of catheter, the child passed urine in good stream from the tip and is doing very well without any need for further surgery after 6 months of checkup.

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. One year boy failed distal hypospadias operated. 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.

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).

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.

6 months later, the child is passing urine well in a nice thick stream and the penis looks like just a circumcised penis.

Master S.K, a 3-month-old baby, was brought to our clinic with abnormal sexual organs of the baby. The referring doctor could not say whether it was a boy or a girl. A child with Disorder of Mixed Gonadal Dygenesis.

On clinical examination, the child had a severe hypospadias and right sided undescended testis which could not be felt on clinical examination.

A Disorder of Sex Development (DSD) was suspected and detailed testing was done. Ultrasound showed uterus behind the vagina. A special X-ray test called Retrograde Genitogram confirmed the presence of vagina, uterus and right fallopian tube.

Karyotype was done to study the chromosomal sex of the baby and it was 46XY/45XO instead of normal 46XY. 46XY/45XO karyotype is called a mosaic type whereby in 50% cell lines of the body Y chromosome is missing. This leads to faulty development of the reproductive organs. Based on this a diagnosis of Sex Chromosome DSD was made (also called Mixed Gonadal dysgenesis).

After a detailed discussion with the family and considering that the penis development was adequate, a male sex assignment was considered. Dr A.K.Singal along with his team discussed the case in detail.

Surgery was done to remove female internal organs and at the same time Single Stage Urethroplasty was performed using Modified Koyanagi Repair. Dr V.R.Jayanthi from Nationwide Childrens Hospital & Ohio State University, USA was the Chief Surgeon during the Surgery. A second minor repair for a urethral fistula was performed 6 months later; now the baby is 5 years old and is doing well.

Later at 12-13 years of age, he will need counseling and some hormonal replacement to help him with sexual function. He will be infertile but a functional individual having a proper meaningful role in the society, taking care of his parents and family.

Discussion on Disorders of Sex Development (DSD)

DSD or Intersex is a disorder where the sexual differentiation has not been completed. During the development of a normal child inside mother’s womb- till 2 months of pregnancy, it is impossible to distinguish whether it is a boy or a girl. Only after that depending on the chromosomes and hormones, sex is determined.

Sexual differentiation into a male or a female is a very complex and well orchestrated process and sometimes things may go wrong.

A baby may be born with incomplete sexual differentiation into a male or a female. Such condition is called ambiguous genitalia or Intersex.

Commonly these children may present with severe hypospadias, hypospadias with undescended testis or absent testis, ambiguous genitalia, clitoral hypertrophy etc.

It is important to realize that these kids except for the sexual organs are absolutely normal and can function as valuable and meaningful citizens. Just like a heart or brain disease, it is a medical disorder which is treatable.

With the advances in medicine most of these kids can be offered a good hormonal and surgical therapy which will remove the ambiguity and give them a functional male or a female status.

The problems these people face are from three fronts:

• Social
• Personal low self esteem
• Inadequate health care

As a result these kids are taken away by eunuch societies in their young age and denied a meaningful role in the society.

Team Effort is important in managing these children:

• Role of the family

o To seek proper medical help
o To emotionally support the child

• Role of the primary care doctors

o To refer these kids to a specialist as a early as possible
o Not to make hasty sex assignment as it is not possible in all cases to continue with the sex of rearing.
o Not to be judgmental and pass casual statements
o To maintain patient dignity and privacy.

• Role of the society

o To treat such kids as just another medical disorder
o To understand and offer equal opportunities in life
o To formulate legislation and create awareness about such disorders, that they are treatable like any other disorder.

Adult Redo Hypospadias using flap repair after a failed surgery in childhood, A.D, a 24 years old young man had a failed hypospadias repair (elsewhere) at the age of 4 years and at present he came to us with multiple issues:
• Passage of urine from multiple holes on the underside of penis
• Persistent mild chordee
• Unsightly skin bridges and scarring on underside of penis.
On examination- the above findings were confirmed (pic1).

A single stage repair was planned. As a first step- the whole of terminal unhealthy urethra was laid open till the last hole and scarred skin and tracts were excised. A novel flap based on dartos was designed from the lateral aspect in sub-glanular region and this was flipped horizontally as an ONLAY flap (Jordan’s flpa) to make a neourethra. At the same time a 12 O’clock tunical plication was done to correct the mild chordee.
Post-op the healing was very good and at present A.D. is passing urine in good stream and has absolutely straight erections. He is extremely satisfied with the functional and cosmetic outcome.
According to his father- he has gained a new confidence and outlook ever since he has started feeling normal about his sexual organs.

Adult Redo Hypospadias using flap repair

Dr Singal and Dr Dubey have an extensive experience in dealing with re-operative hypospadias who have failed surgery elsewhere. The various innovative techniques used are:

1. Parameatal flap
2. Transverse island flaps from nearby skin
3. Dorsal flaps rotated ventrally
4. Buccal mucosal patches/ grafts

Even in the face of falied multiple surgeries, an attempt is made to repair with a single stage flap surgery. Sometimes when the tissues are really scarred and unhealthy, a staged repair is offered which includes excision of the unhealthy tissue in first stage with buccal mucosa grafting and then tubularisation in the second stage.

Also Read: Redo Hypospadias Repair Using Flap Repair After A Failed Hypospadias Repair

Severe Hypospadias needing a Staged Urethroplasty, A 2-years-old boy was brought to Dr A.K.Singal for repair of severe penoscrotal hypospadias (hypospadia) with chordee- the penis was bent at almost right angle- op degrees angle.

The hypopadias repair surgery in such cases involves chordee correction (straightening of the penis) and then urethroplasty to bring the urinary opening to the tip of the penis. The first step in chordee correction surgery is to deglove the penis which means all th skin is taken down and almost 50% of the cases chordee correction happens with this step alone. Some cases may need a stitch on the top side of penis called Tunica Albuginea plication to correct the curvature. But in this case the chordee was very severe and even after degloving the penis was very bent. In such cases, stitch on the top side of the penis may not work.

First Stage:
As a first step, we degloved the penis but still there was significant chordee.

This was due to shortage of tissue on the underside of penis. We made a horzintal incision at the site of maximum curvature first dividing the urethral plate and then on tunica albuginea  to straighten the penis. As soon as this was done the penis became straight.

There was a large oval defect in the tunica albuginea on the underside of penis. This was covered using a “dermal graft” from nearby inguinal region. Dermal Graft refers to a strip of skin without the top layer and hair follicles.

The graft was sewn into place using PDS sutures and leak checked.

After that the foreskin  (prepuce) was divided in midline and rotated onto the underside to cover the whole penile area completely. At the end of it, the boy had a straight penis without any chordee and enough of skin n the underside for the second stage repaur of hypospadias (urethroplasty)

Second stage hypospadias repair surgery was done after 6 months. To begin with the strip of skin on underside of penis was rolled into a tube with thick dartos cover.

Second Stage:

Then a second layer of tunica vaginalis s placed and finally the mobilized skin on underside of penis was closed with interrupted sutures to finish the repair.

A 1.5 years old boy was referred to us from Goa with severe hypospadias and chordee, diagnosed as scrotal hypospadias with chordee. The urinary opening was near the end of the scrotum. The penis was also significantly bent (chordee). Since our center specializes in single-stage urethroplasty, we decided to do a single-stage repair, specifically Child Severe Hypospadias Koyanagi urethroplasty.

As a first step, the penis was degloved and the chordee was corrected using 12 O’clock tunica plication. The Koyanagi flaps were raised on either side, going on the top of the penis, and these were then joined together in the midline and finally tubularized using 6-0 PDS over 8 Fr stent.

Second layer coverage was done with Tunica Vaginalis flap and prepuce on top was split in midline and brought ventrally or coverage of skin. The child did very well and required no further surgery.