Hypospadias is a urinary birth defect in which the urinary opening is on the underside of penis rather than being at the tip of the penis. In more than 50% of patients with hypospadias, the penis is also bent downwards – this penis curvature is called chordee. Hypospadias affects 1/150 newborn boys and hence more than 1 lakh (1,00,000) kids are born in India with hypospadias every year. Worldwide the incidence has increased probably due to increasing burden of chemicals and pollutants which act as endocrine disruptors (chemicals which block male hormone action) and have contributed to an increasing incidence of hypospadias.

Most of these kids except the ones with very minor glanular hypospadias without chordee will need surgery. The surgery is ideally done between 6months-18 months for age of the child was born with good weight and full pregnancy, if the child is underweight or preterm or has any other major anomalies then it may be better to wait till the child is about 3 years of age.

When and how does hypospadias happen?

Hypospadias results from defective formation of urinary tube during 8-12 weeks of pregnancy and hence if there is an interference with penis development after 12 weeks of pregnancy, hypospadias cannot happen as penis formation with urinary opening at tip is complete by 12 weeks of pregnancy. Between 8-12 weeks of pregnancy, the urinary pipe forms under the penis from the base to the tip under influence of testosterone and dihydrotestosterone. Along with the urinary tube the various covering layers of the penis such as spongiosum , bucks, dartos and skin also also formed. Hence when the urethra remain short of tip, all surrounding layers also become short.

Is Hypospadias repair surgery covered by insurance companies or corporates for cashless treatment or re-imbursement?

Hypospadias being a penis birth defect is classified as an external birth defect which can be easily diagnosed as soon as the baby is born. Hence, if parents take an insurance policy after the baby is born, hypospadias surgery treatment costs are not covered by most of the insurance companies in India atleast while in USA, UK it is covered under insurance benefits.

The situation is different for some of the corporate insurance group policy holders. Some big corporates like TCS, Reliance, L & T, Siemens etc issue very employee friendly mediclaim policies which cover all medical and surgical treatments for the employees and their families. Such mediclaim policies cover all pre-existing as well as birth defects for their employees and hence hypospadias repair procedure may be covered by the insurance company by some of these companies.

If insurance does not cover the hypospadias treatment, how much does it cost for Hypspadias repair surgery?

If the insurance company is not covering the treatment, then the parents will have to pay the full charges themselves out of their own pocket. For new parents working in a job or middle class environment this may be financially stressful. What really helps is that Hypospadias repair surgery is a planned procedure. It can be done anytime between 6 months-15 months of age giving parents enough time to rally around and arrange everything from money to other resources. The cost of hypospadias repair surgery depends on the type of hypospadias, complexity of repair, which hospital as well as which type of room one chooses to stay in hospital. On a ball park figure it may wary from 75000 Indian rupees for a minor hypospadias surgery in Hypospadias Foundation to even 3,00,000 Rupees for a complex severe hypospadias surgery in a single deluxe room. Hence, it is best that they meet a hypospadias expert or a pediatric urologist early on in first 3 months of baby’s life and then learn everything about the cost of hypospadias surgery, hospital stay, pre-hypospadias surgery tests and then get mentally prepared for the actual surgery.

About Hypospadias Foundation, Navi Mumbai, India

Hypospadias is often diagnosed at birth or in the first few weeks when a pediatrician does a general examination. It may be a time of great anxiety for the parents when they learn that their child has a urological abnormality which may need surgery. The word surgery may be itself be scary and on top of that surgery on a child and that too on penis. That being said, results of hypospadias repair procedure are very good now, mostly with a smooth pre surgery and post surgery course.

Parents often wonder about what needs to be done before the hypospadias surgery in terms of preparation. Hence, we have tried to put some of this information in this blog which is more general in nature as the specific information can be only shared by the actual hypospadias expert surgeon managing the child.

Before the surgery, besides the usual tests for fitness to make sure that the blood parameters are fine, we always ask for thorough examination to make sure that the child is not having any other concurrent illness such as respiratory, skin or intestinal infection. If the examination and the tests are normal, then we sit with the family and fix up a date for surgery. If the date is far out, we call for another review one week before surgery to ascertain that everything is ready for surgery. Sometimes the parents and families are travelling to us from a long distance away from within India or other countries, then we try to conduct a phone call one week before the hypospadias repair. In our pediatric urologist services, we try to keep hypospadias operation as the first case every day. This ensures that the staff is in the best of their spirits and best of their energy.

1. Empty stomach: The child needs to be empty stomach for atleast 4 hours for breast milk and 6 hours for solid foods/ breads on the day of surgery before surgery. This is a mandatory safety precaution to prevent vomiting during anesthesia. Keeping a 6 months or a one year old child hungry for 4 hours is not an easy task. Infact some of the parents are more worried about keeping a young child hungry than the actual surgery but this is something which is non-negotiable. Often we give the child light sedative syrup 1-2 hours before surgery to help the baby sleep.
2. Bathing: We ask the parents to give the child a bath on the morning of hypospadias operation as it will be difficult to give a formal head to toe bath for next 5-7 days after..321 surgery.
3. Potty: Some of the children may be a little constipated, we advise parents to give a glycerine suppository or a laxative the night before so that the child has an empty bowel. Post hypospadias surgery, local pain often leads to a temporary constipation.
4. Admission: In a hospital with daycare facility, we admit the child for hypospadias operation at 6:30am -7am. If the parents live farther away from the hospital or the hospital doesn’t have a daycare facility, we like to admit the children the night before surgery. At Hypospadias foundation in Navi Mumbai, India we mostly admit the children in the morning of the surgery itself unless the parents live more than 50km away or do not have a means of traveling early in morning.
5. Clothes: Children are changed into hospital clothes appropriate for their age on the morning of surgery. Make sure that the iv canula is inserted after changing of clothes.
6. Sedation: If the child is irritable while staying hungry we either advise a pacifier or a light sedative syrup till the time of anesthesia.
7. Induction: Crying child is not a good sight just before hypospadias surgery for the parents or the hypospadias doctor. If the child has an iv line, anesthesia team often administers a small dose of premedication to help sedate the child before shifting to operation theatre.
8. Consent: Before hypospadias surgery is started, family has to fill up an anesthesia and a surgery consent form which is quite detailed in general. Sometimes the parents get alarmed on seeing the form. But please feel free to ask us about any doubts which you have. We always have the best of intentions and efforts to get your baby back home safely after hypospadias surgery.

We must understand that getting the child with hypospadias fully cured is a team effort and it needs devotion and patience from both the family as well the surgical team. We at Hypospadias Foundation are committed towards making the whole hypospadias treatment experience seamless, less bothersome, more baby friendly and easy for the families. This also translates into better results sheerly stemming from deep interest in wellbeing of babies with hypospadias.

Please contact us if you have any questions for us by submitting your query here. Dr Singal and his team will be more than happy to help.

Dr A.K.Singal is a renowned and one of the best Pediatric urologist’s in Indian subcontinent. He is known for excellent results and devotion to managing children and adults with hypospadias and Disorders of sex development. He runs his urology and hypospadias clinics in Navi Mumbai and Mumbai area of western India. Dr Singal is outspoken advocate of achieving best results for hypospadias both clinically and psychosocially.

Letter from Across the Seas:

Dear Dr Singal,

Trust all is well with you. We are glad that we came all the way to India to you for our boys and are thankful to you for treating our boys with such care and in a single stage surgery for Hypospadias. As discussed, I have written the write up for the blog. These are basically my views, learnings and tips for other parents, especially the Hospitalization including pre-surgery and post hypospadias surgery course.

Regards,

S.P.

Dubai

THE WRITE-UP

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Dear Parent,

As parents we all are concerned for our child(ren)’s wellbeing. We interact a lot with Pediatricians and Specialist Pediatrician from birth till their teens. From Vaccinations to Major surgery we ensure our child(ren) gets best of the treatment and care. Until both my twin boys were detected with Hypospadias, I was inexperienced and the entire journey from initial diagnose to surgery has taught me a lot.

Here are some tips, learnings and guidance for parents

Before the meeting the Doctor

1.    Most cases of Hypospadias are detected at birth. The Pediatrician at birth may not be expert enough to guide further so it’s better to consult a Pediatric Urologist or expert hypospadias surgeon as soon as possible.

2.    There is no benchmark for earlier consultation, but its better the visit to the Pediatric Urologist when the child is less than 6 months old.

3.    If you are an outstation patient and are communicating with the doctor over emails ensure you share following info:

• Baby’s Allergies and medications
• Any special medication or condition
• Any hospitalization and the reason

Sometimes this information doesn’t affect the course of hypospadias surgery but its always safe to share as this helps the anesthesiologist for planning a safe anesthesia

4.    If you have a limited timeframe for your visit than

• Check if there are any further tests (like blood or urine tests) or investigations required before you meet the pediatric urologist
• As required by the doctor, perform the tests and send the reports to doctor for further guidance. This can be done via email. Since I was traveling from Dubai, I did these tests as recommended by Dr Singal even before I landed up in Mumbai
• Sometimes a certain blood count such a hemoglobin may be needed to be normal before hypospadias repair procedure is required to perform before surgery and if the count is not as preferred it may take month to reach the desired level.

5.    Check for the travel plans of the doctor so that it doesn’t clash with your visit. Sometimes the doctor maybe traveling for vacation or for a conference.

6.    Convey your travel plans to the doctor

Once you meet the doctor, most of your doubts will be cleared in the initial meeting. A date for hypospadias surgery will be decided in the meeting. If you have questions or doubts regarding the hypospadias treatment procedure please ask the doctor, he will be happy to guide. Sometimes you may have doubts or questions post consultation check with the doctor if you can email for such doubts. The doctor may suggest hospitalization before the day of the surgery and also some additional tests whenever needed.

My twin son’s both had hypospadias and we elected to have surgery for first kid on Monday and second one on Tuesday.

When we reached the hospital we had some minor issues as it was Sunday and we were supposed to see the doctor on call in ER. Since they were already alerted for our visit the doctor on call was prepared with all the requirements. They were to do a blood test on one of my twin. To avoid double prick they decided to insert cannula for one of my boys. And then the hell broke. We had two crying babies (one due to prick and other seeing the first one) and there were hospital formalities to be fulfilled.

Hospitalization

1.    Before admission to the hospital

• Reach hospital half an hour before the schedule time.
• Insist – The Cannula And Blood Tests Be Done Only After The Kid Is Settled In The Room
• Request for the allotment of room and fulfill all the formalities
• Ask for hospital clothes for the baby
• Change the baby in hospital clothes
• Once the child is settled than ask doctor on call to the needful

2.    Inform the hospital staff if your child is on a special diet and if they can provide.

3.    Carry baby products – wipes, diapers, any special food or milk powder you may be giving, soft toys which soothes them

4.    Carry you basic requirements for two days of hospitalization

5.    Since the hypospadias operation will be done under anesthesia, check till when the child be given food/water/milk.

 After Care

1.    Learn to change the baby double diaper. We were happy as with double diaper technique the babies were nicely tugged in and there was little fear of catheter dislodgement.

2.    Learn the medications of the baby

3.    Don’t discontinue medication unless the doctor advise

4.    Follow up visits with the doctor

The child will have discomfort and can be cranky due to operation the doctor will guide you. This is a normal phase after any surgery with children as penis is a sensitive organ and pain may be there for a first few days. But as one learned person said “ This too shall pass” It did pass for us. Now when we look back, the difficult days just went by in a jiffy. With the love and support of Dr A.K.Singal, junior doctors and nurses, we saw them through.

My personal advice – Stay Calm and positive through the process.

All the best

Regards,

An experienced Parent

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Please feel free to write to us for an opinion at hypospadiasfoundationindia@gmail.com or fill this contact form http://hypospadiasfoundation.com/contact-patient.htm

Watch videos on our Youtube Channel:

https://www.youtube.com/watch?v=HGRDZGXlffY

https://www.youtube.com/watch?v=M9_buN10lUE

Why is dressing needed after hypospadias surgery (urethroplasty)?

As after any surgery, a dressing is required after hypospadias repair as well and the reasons for this are many.

• The dressing helps to prevent infections by creating a physical barrier as well as supports the penis in the healing phase.
• Penis is an organ which has a tendency to swell up after surgery or any trauma and thus a dressing helps to support the organ in the healing phase after hypospadias surgery.
• Besides these two major goals, some surgeons use the dressings to prevent bleeding after surgery but with the refined techniques and more experience, bleeding has become less common issue surgery and we at hypospadias foundation generally use a very loose dressing as prevention of bleeding is generally not the goal for the application of dressing.

When we were in surgical training, we had a standard firm elastocrape dressing which used to be applied tightly and was resultantly difficult to remove. The advantage, though, was that it would remain in place without the risk of getting dislodged. On a personal front, as a resident doctor asked to remove those bulky sticky dressings, I was never happy with the dressing as it was difficult to apply, difficult to remove and I felt that it would cause too much of pressure on the healing tissue at the cost of impairing circulation. Also the healing area will not get air to breathe. I was worried that this may result in poor healing as well.

Over the last few years though the primary goals of dressings have remained the same, the dressing after hypospadias surgery itself in our practice has become very easy to apply and remove.

What we use is the following:

At the end of hypospadias surgery, we put a transparent cling wrap kind of dressing called – Tegaderm film- on to the penis – the operated site. This is light in consistency, does not stick to the tissues, is easy to remove and it allows passage of air through it thus aiding in healing.

Over the Tegaderm film, we apply a couple of rolls of thin white gauze just to support the penis and this layer is kept loose and just functions as a soft scaffolding.

A small piece of sticking tape called micropore is applied to hold the gauze piece and the catheter in place and this step finishes the dressing.

In some children, if the dissection has been extensive into the scrotum or the penis length is short we apply a sandwich type of dressing over the whole area instead of a rolled dressing.

Double diaper care- finally the catheter is brought out through a small hole in the inner diaper and left to drain in the outer diaper. Double diapers also help in keeping the area snug and dry during the healing process while allowing the children freedom of movement.

We believe a loose dressing after hypospadias surgery allows good blood circulation to operated area after surgery and thus faster healing. Also, we have observed that the pain is much less with this type of dressing. This dressing is also very easy to remove in the outpatient department during follow up.

What can go wrong with hypospadias dressings?

Dressings can get dislodged fairly frequently after hypospadias surgery. If this happens during first 2-3 days we like to do the dressing again in clinic. But if this happens after 3 days, we just remove the dressing completely and apply antibiotic ointment on the operated area 3-4 times a day and at every diaper change.

When do we remove the dressings

We generally remove the dressings on day 5-6 but in certain distal hypospadias we like to remove the dressings along with the catheter on day 7 after surgery. Removing them together avoids one opd visit for the family.

How are dressings removed after hypospadias surgery/ urethroplasty?

Dressings are removed in the outpatient unit by the junior doctor or the treating surgeon by gently teasing them out. Sometimes normal saline is used to ease out the dressings by making them wet. We have seen that tegaderm based dressings slip out fairly easily in clinic. The only caution to make sure that the catheter is not accidentally pulled up while loosening the dressing.

What happens if there is bleeding into the dressing?

Minor bleeding after hypospadias surgery is fairly common and happens as penis has very robust blood supply. Generally this occurs as a small amount of blood spotting or drops of blood at the tip of penis. If the bleeding stops by itself, nothing needs to be done and this is generally the case. If the bleeding is more in quantity, we ask the parents to visit us and a tighter dressing may need to be applied.

What happens if there is urine leakage into the dressing?

Small amount of urine leakage by the side of the catheter into the dressing is common. If there is lot of urine leakage by the side of the catheter then this means that the catheter may be blocked. The surgeon can then flush the catheter to relieve the block and the leakage will stop.

What happens if there is potty staining of the dressing

Sometimes the children may have loose motions after hypospadias surgery due to side effects of the antibiotics. These may then leak and stain the dressing. In such a case you should wash away the stools and visit the Hypospadias Foundation/ Mitr Hospital to get the dressing changed or removed. If dressing is left potty stained for long, this may allow the bacteria in potty to cause infection in the freshly operated hypospadias.

What care to take after removal of dressing

Child can be given warm tub bath twice a day and an antibiotic ointment should be applied on the operated site 4-5 items per day.  Inner Diapers should be changed at least 2-3 times per day and outer ones as soon as they are full with urine.

One of those questions which parents often ask and which is probably one of the most difficult to answer. But none the less the Question requires its due answer! To start from the basics, Hypospadias is a condition which is generally diagnosed immediately after birth by the pediatrician / neonatologist. The anomaly is very evident by an incomplete prepuce (foreskin), bare glans (head of penis), often a bent penis (called chordee) and misplaced urinary opening. Mostly it is an isolated anomaly but sometimes there may be an associated undescended testis with hypospadias. Since hypospadias is diagnosed at birth, ideally the child should be referred for a surgical opinion from a pediatric urologist or a surgeon trained in doing hypospadias surgery in the first few months of life. Early referral helps as the parents can then plan their lives around treatment of hypospadias. Hypospadias is a problem that always requires surgery called urethroplasty except in very minor varieties such as glanular hypospadias without chordee. It has been shown in multiple clinical studies that children do better when they are operated for hypospadias in infancy itself, ideally around 6-12 months of age. The reasons for these recommendations are multiple:

1. At this young age the tissues are very soft and tend to heal very well after surgery.

2. Emotional and psychological issues around getting operated in genital area are non- existent at this age.

3. Once the surgical result has been good – children at a later age don’t even notice or come to know that they ever had hypospadias as there is hardly anything to differentiate these children from other children. For most of the distal and moderate hypospadias, penis after surgery just looks like a circumcised penis. There is also a debate whether these children should actually be told that they had hypospadias earlier on in their life.

4. Incidence of wound infection, post surgery bleeding etc are much less at younger age as bacterial colonization is much less.

5. Post- operative pain and erections are less common at this age.

6. Management of a small child in diapers and urinary catheter is much easier in infancy. Typically we use a double diaper care where the catheter is brought out through a small hole in the inside diaper to drain into the outer diaper. The inner diaper remains dry and thus prevents rashes and outer diaper is changed whenever it gets wet with urine. In an older child, diapers are very difficult and bulky to use.

Considering all this, the general consensus of American Academy of Pediatrics is to recommend surgery between the ages of 6 months to one year. At hypospadias foundation and MITR Hospital, we have been operating children around the age of 6-9 months for the last few years with excellent surgical results and happy parents. Once the surgery and the post operative recovery period is over, parents often come and tell us that it was a good decision that they got their kid operated at this early age and now all their worries are over. Some of the parents still worry about getting their kids operated in infancy and come at a later age for surgery. We and the staff can then see the difference in the recovery and post operative issues when compared to younger kids undergoing hypospadias repair. Another way to look at this is that a child with hypospadias will always need surgery, this is a condition which will never get better on its own. The longer we wait, more the parents will think about it and feel anxious. So earlier dealt with, the better it is for everyone. It is definitely better for the kid but it is in a way better for the family and parents as well. And surely it is better for the doctor as his job is to give the best results and post operative comfort.

One of the important concerns for parents when their little ones are advised a surgery for hypospadias (urethroplasty), are risks associated with surgery. These concerns are true for a kid who is undergoing surgery for hypospadias as well. Safety is the foremost factor for parents while deciding a surgery for their kid.

Same concern is valid for doctors (Pediatric Urologist, Anesthetist) and hospital team also. In some sense the safety checklist and precautions are important for any surgery which we plan to do in a child.

The risks mainly stem from anesthesia which is needed for performing a surgery in a child. There are other risks associated with Hypospadias surgery itself but none of them are life threatening.

To make surgery and anesthesia safe, the following precautions are undertaken:

1. Pre-operative checkup for fitness: Blood and urine tests are done to make sure that the child is fit enough to undergo surgery and does not pose an increased risk of anesthesia. This also includes a thorough clinical examination to make sure that there is no infection lurking anywhere. In presence of any obvious infection such as cough, running nose, fever, diarrhea, skin infection etc it is better to postpone the surgery till the child recovers fully from infection. Infection leads to higher chances of infection at operated site and also slows down healing as body’s energy is spent in fighting the infection and thus healing takes a back seat.
2. Sterile precautions: Instruments are properly sterilized the day before surgery and packed properly. The operation room is disinfected the evening before and locked. All sterile aseptic precautions are followed during scrubbing, draping etc.
3. Availability of proper pediatric anesthesia equipments: Appropriate sized anesthesia equipment such as breathing tubes, masks, connectors, tapes, syringes, intravenous canula, intravenous infusion sets, needles, well calculated & checked anesthetic medicine doses etc are kept ready and labeled. Every single dose should be cross checked and labeled. Emergency medical equipment is cross checked before every single case and kept ready.
4. Prevention of low body temperatures during surgery: Small children tend to lose a lot of body heat under cold environs of the operation theatre and thus get cold during surgery. The low body temperatures are called hypothermia. This can lead to multiple complications such as prolonged recovery from anesthesia, higher risk of infections and shivering. Hypothermia is best prevented – the steps taken are blanket to cover legs and upper body leaving only the lower tummy till mid thigh exposed for surgery, head cap and warm bandage rolls on arms and legs, electronic warming blanket underneath the baby set at 37-38 degrees, using warmed disinfectants, setting the AC temperatures to 25-26 degrees and not keeping them too low and then keep less operative area exposed and covering the rest of it with surgical drapes. For Hypospadias anyway a small area is exposed after preparing the middle part of the body with disinfectants.
5. Dedicated Surgical equipment for kids: These include miniaturized microsurgery urethroplasty instruments, small retractors, small sutures (almost as fine as hair), fine clips, suction apparatus and smaller drapes. Larger instruments can crush the delicate tissues of kids and lead to poor surgical outcomes.
6. Trained professionals: Doctors and nurses handling the kids undergoing surgery should be well trained in understanding that the kids are not small adults, their body behaves differently, the drug does should be perfect . The doses have lesser error margin and thus need to be calculated, cross checked and properly labeled. Putting an intravenous line requires training for handling kids and most importantly the Pediatric Urologist surgeon and the anesthetist should be very well trained in managing kids. Even a small excess of intravenous fluids during surgery can lead to major complications, that is the reason why pediatric infusion sets and connectors are very different from those in adults.
7. Baby friendly environs of hospital: At MITR Hospital & Hypospadias foundation, we ensure that the kids are kept happy and engaged by the staff and the doctors during their hospital stay.

Happy kids have a faster & better healing and this also decreases the complications of surgery.

One of the common questions which the parents ask in clinic when I counsel them for hypospadias surgery is “how many days will it take for my kid to recover after hypospadias repair/ surgery”

And my answer though very detailed, could be read two ways

One I am avoiding a straightforward answer and the second may be that I 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 of many types.

The immediate and the most concerning is the Recovery from anesthesia and this usually within 2-3 hours after surgery implying that the kid will be able to talk, converse and start taking liquids etc after surgery. Usually after 6-8 hour of surgery kids can take solids and normal diet. We have made sure that our operation theatre and the surgical team is baby friendly to make sure that the recovery is fast and kids go home fast. The anesthesia used is caudal plus sedation in most cases, there is a warming mat under the baby 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. Above all the hospital staff at MITR makes suresthat the child is well cared for and parents are made comfortable during the stay.

Recovery to playing and walking etc usually happens by evening and often I find kids fully comfortable and running around 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.

Recovery from dressings & catheter takes more time. After hypospadias surgery, usually after hypospadias surgery at 4-5 days and catheter after 7-10 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 one week of surgery. This saves unnecessary visits to the hospital. Over all intent is to make hospital visits for the kids as less as possible.

Recovery 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 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.

Penis is an organ which has a tendency to swell up at the slightest excuse be it a minor infection, injury and this happens quite significantly after hypospadias surgery. Equally importantly the penis is also an organ which heals very fast and almost normal skin cover comes back even after an extensive repair which a lot of penile skin gets rearranged during surgery. 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.

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.

We have started using specialized Tegaderm and light gauze dressings as these do not impair the blood supply by putting the pressure on already swollen penis after hypospadias surgery. Also, a loose dressing decreases pain and allows tissues to breathe.

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 fairly easy to take off in outpatient clinic mostly by junior staff. Catheter is held by a small fine stitch to the glans and this can b easily cut in outpatient clinic to remove the catheter.

Understanding postoperative problems after Hypospadias Surgery (Urethroplasty) in children

This is the second most common question asked by the parents when I counsel them for surgery for hypospadias!

After Hypospadias Surgery (urethroplasty), this is often the most important management issue for the parents – though more for the mother than for the father. We as clinicians may often focus more around the medical issues – the pre-operative checklist, the steps and arrangements for hypospadias surgery, the stitches, antibiotics, anesthesia and dressings. But what about the rest of the issues – what about the child himself, the issues which parents face may face 24/7 like pain, food, tantrums, diaper changes, naughtiness management etc. I guess it is time that we doctors should see 360 degrees around whatever goes in treating a child with hypospadias. We should attempt to cross the line to the other side and think like a parent and then should be open to discuss all these questions and answer them placing ourselves in parent’s shoes.

So here are the facts as we see them:

1. Pain: The main concern after surgery is often the pain. Since penis is very sensitive organ with intricate nerve supply, sometimes there may be significant pain for the first 3-4 days. But pain is also a variable symptom as intensity may vary from one child to another. Sometimes children who have undergone severe hypospadias repairs lasting 3-4 hours do not complain of pain at all and are running around pain free the next day while some children with a minor hypospadias repair may complain of a lot of pain. We usually prescribe enough pain killers and antispasmodics to care of pain as well as bladder spasms but still the kids may be a bit irritable for the first couple of days.
2. Diet & feeding: We generally allow children liquid feeds 3-4 hours after surgery and then gradually advance to a full diet by evening itself. Sometimes the children may be a bit sleepy and fussy for a few hours after surgery but eventually most of the kids are on full normal regular diet by the evening of hypospadias surgery.
3. Diaper care: Children are kept in a Double Diaper Care Program after surgery to avoid catheters hanging with a bag. A small hole is cut out into the front side of the inside diaper and the urinary catheter is taken out through this to drain into the outer diaper. The inner diaper thus needs to be changed whenever the child passes stools or twice a day atleast and outer diaper whenever it gets wet with urine. Double diaper care allows the child to move around, walk or play without the bag hanging to his waist or leg. Also, the chances of a catheter getting accidentally pulled out are much less when it is draining within the diaper.
4. Medicines: There are about 4-5 medicines in liquid syrup form which are administered to the baby after hypospadias surgery. These are an antibiotic, a pain killer, an antispasmodic and a medicine to prevent side effects (acidity) due to pain killers. In bigger children, we also prescribe diazepam to prevent painful erections. Medicines are usually given for 7-10 days after surgery.
5. Catheter care: Catheter is a plastic tube which is placed into the bladder and thus supports the new urethra. Catheter drains the urine continuously into the diaper and allows the stitches to be dry during the critical phase. The catheter is kept for a period ranging from 5 days to 12 days depending on the type & complexity of repair.
6. Dressing issues: At the end of hypospadias surgery a soft gauze dressing is applied on the penis and this is generally removed after 5-6 days of surgery. Sometimes there may be a small amount of blood staining after surgery or dressing may slip off after 2-3 days but this will not affect the outcome at all. After dressing is removed, the penis may look swollen and reddish as penis is an organ which swells frequently after surgery. The swelling goes away on its own in 1-2 weeks time and raw areas also heal up very fast.
7. Minor bleeds: Penis being a very vascular organ has a very rich blood supply. There may be a minor bleed from the head of the penis in the first 2-3 days after hypospadias surgery. This generally presents a spotting on the diaper or the dressing.
8. Cosmetic outcome: The final cosmetic aim of hypospadias surgery is to give a circumcised appearance with an absolutely straight penis. The meatus should be at tip with a slit like normal appearance. The final cosmetic outcomes will take about a month after surgery to be seen.
9. Cleaning and bathing: Children are not allowed formal full body bath for a first 4-5 days after surgery till the time the dressing is in place. Sponging can be done taking care not to wet the dressing. Once the dressing has been removed it is advisable to give warm tub baths twice a day for the next two weeks. This allows the warm water to wash away all the clots and debris and swelling also reduces. After bathing, the penis should not be dried while rest of the body can be dab dried. Ointment is applied and then the diapers can be placed.
10. Follow-ups: Follow up is done day 5-6 after Hypospadias surgery and then at catheter removal, one week, one month and 3 months later. Healing, caliber of the new urethra is assessed at every follow-up. This may include a gentle calibration with a catheter by the doctor in the clinic itself.
11. Naughtiness management after hypospadias surgery: This is the most difficult question to answer as there is no single answer to this issue. To me all the kids are naughty and all of them manage fairly well after surgery. I haven’t heard too many parents cribbing after surgery that they had an issue with managing the kids. There are so many ways to keep the kid happy after surgery like toys, books, video games or just being around.

Nothing is better than actually quoting the questions posed by parents and answering them as I would do in my clinic. So here is a set of questions asked by a very concerned father recently on an email and I have tried my best to answer them using my last few years of experience in working closely for children with Hypospadias.

Dear Dr Singal, This has reference to your consultation at MITR Healthcare Hospital for my son Master  XXXXX (6 months old) on xx/xx/xx. My son was diagnosed with Hypospadias soon after birth and was advised for correction surgery. We are basically from xxxx city and I was visiting my in laws at that time and took my son to you for consultation. After consultation you had advised a single stage surgery.

My wife and myself have decided of doing the surgery from you in Navi Mumbai at a hospital which you will advise. As parents it is difficult for us to accept the fact that my son have such problem and at such a tender age he has to undergo surgery, I hope you are able to understand our situation and feeling. As parents I have some queries regarding the surgery. 

1. How long will the procedure take?

Answer: The surgery for hypospadias (urethroplasty) can take anywhere between one hour to three hours depending on the severity of hypospadias, associated bend in penis (chordee) and type of surgery performed. In your son’s particular case, since he has a penoscrotal hypospadias my assessment would be that since this is a moderately severe hypospadias, the surgery may take about 3 hours.

2. Will he be given general anesthesia?

Answer: For minor hypospadias surgeries lasting less than 2 hours, we generally give regional anesthesia (caudal epidural block) for pain control/ relief with sedation (so that the child sleeps comfortably throughout the procedure). Hypospadias surgeries needing longer time than that generally require full anesthesia and I guess that will be the situation with your son’s surgery.

3. Will he be 100% cured after the surgery. I mean to say will he be able to stand and pee/urinate like other male child?

Answer: Results of surgery for hypospadias have improved considerably. Please read this blog for more information- http://www.hypospadiasfoundation.com/hypospadias-blog-by-dr-a-k-singal/how-to-prevent-failures-in-hypospadias-surgery-urethroplasty/ buy kamagra online

Currently, more than 90% of the children with penile hypospadias get successful results after single stage surgery and children are able to stand and pee like a normal kid a few days after surgery. In some children, a minor second surgery may be needed if there is a fistula or a stricture.

4. Will his penis look normal like others?

Answer: During hypospadias surgery, we usually take tissue from extra foreskin on top and use the rest of it to provide equal skin cover on all sides to penis. At the end, the penis has a circumcised appearance. Also, if there has been any bend in penis, that is corrected leading to straight penis after surgery. So in nutshell, in most of the cases a few weeks after surgery, penis looks like just that a circumcision has been done.

5. Will the surgery affect his sexual life later on? I mean to say will there be any issue regarding erection, semen ejaculation etc?

Answer: Generally with current surgical techniques preserving nerve and blood supply, the repairs have resulted in very good outcomes both from cosmetic and functional perspective. Some children who have undergone a flap procedure for a severe hypospadias such as for scrotal hypospadias may need an evaluation as the force of semen ejaculation may not be very good. Also a check-up is mandatory later on after puberty at about 13-24 years of age and after 2-3 years of sexual life/ marriage to ensure that the urethra is functioning well.

6. I have gone through internet a little bit and have understood there are few types/methods of the surgery like inverted Y tubularised Plate etc. I would like to know for him what surgery will be undertaken.

Answer: For Hypospadias, more than 100 different types of repairs have been described in last two centuries. Some of these have become outdated with new knowledge. Currently, about 7-8 types of hypospadias repairs are done by hypospadiologists worldwide and these include Tubularised Incised Plate Urethroplasty (Snodgrass Procedure), Onlay flap, Prepucial tube, Glans approximation procedure, Barcat Procedure, two stage urethroplasty- Thiersch duplay type, Modified Koyanagi repair etc. The type of repair is dictated by the type of hypospadias and expertise/ comfort of the surgeon with a particular repair.

7. For how long he will have to be hospitalized and what care should be taken post surgery.

Answer: We generally admit the children in morning and do the surgery in the first half itself. Most of the children are able to go home either in the evening or the next day morning. We try to send them home as soon as possible – more info here: http://www.hypospadiasfoundation.com/hypospadias-blog-by-dr-a-k-singal/evolution-in-hypospadias-management/

Some children who have undergone very complex repairs, or surgery for failed hypospadias or come from outside the city – may need to stay for a longer period of time. The post-operative care includes giving medicine on time, regular double diaper changes and regular follow-ups. The child can take normal diet by evening and can play within the house.

8. How regularly follow ups are required?

Answer: After discharge, we generally call the baby for removal of dressings on day 4-5 and removal of catheter on day 7-10 depending on the type of hypospadias. Sometimes the urine catheter may be kept for 12-14 days in complex hypospadias repairs. Then a further follow-up is needed at 1 month after surgery and then 6 months and 2 years after surgery. Another assessment should ideally b done at 13-14 years of age and later on in adulthood once sexual activity has started.

9. What complications apart from fistula can happen also how soon can we come to know whether a 2nd surgery is required or not?

Answer: Other possible complications after Hypospadias Surgery are

a)      Bleeding -Usually rare, minor and stops in 2-3 days.

b)      Infection- less common and even if it occurs is usually superficial and resolves with antibiotics

c)      Fistula

d)      Meatal stenosis: Narrowing of the urinary opening can occur and may need regular calibration or minor cut back called meatotomy in some cases

e)      Diverticulum: This may be seen after a flap repair for hypospadias as the skin flap expands and balloons during passage of urine. With careful trimming of the flap during surgery, this has become much less common.

f)       Stricture: Sometimes during the healing phase, the new urethral tube may become narrow and require further treatment. This is noticed by poor stream, straining during passage of urine and long time taken to pass urine. This may require further treatment in form of dilatation or a second surgery.

g)      Dehiscence/ breakdown: Very rarely, the whole repair may breakdown due to poor healing, infection or loss of blood supply requiring 1-2 more surgeries. This is very uncommon and unfortunate.

We generally get to know about the need for second surgery with respect to fistula by about 1 month after surgery while some other complications like stricture or stenosis or diverticulum may not be apparent till 5-6 months.

Last lines by parents: Please do not misunderstand as we are really very concerned and worried about this and hence we are asking these to you. I look forward for your replies in this aspect. Sorry for asking so many questions.

Answer: Please do not hesitate to ask any questions which you might have. They may sound trivial or silly but please do not have these lurking in your mind. Once we decide to work as a team to get your child better, we should be on the same page and clear all the doubts before surgery. We should also be having the right and identical expectations from the surgery.