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

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

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

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

During the surgery :

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

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

           After surgery :

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

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

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

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

Contacting the Hypospadias Foundation:

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

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Hypospadias and undescended testis (also called cryptorchidism) are both very common clinical problems in young children. While hypospadias occurs in 1/150 boys, undescended testis is even more common. But the treatment for both of them is different.

Undescended testis: What is the usual treatment plan?

When we see a newborn child with undescended testis, we often wait before advising surgery as nearly 60% of the testis which are undescended at birth may come down to a normal scrotal location by 6 months of age. This is even more true if the testis has already come out of the tummy and can be felt by the doctor during the examination in the OPD (palpable undescended testis). For the testis which are higher up in abdomen (intra-abdominal undescended testis) chances of coming down spontaneously are quite less but possible.

Hypospadias: What is the usual treatment?

Hypospadias on the other side, almost always requires surgical correction. And the right age for doing the hypospadias surgery is between 6-18 months of age. We typically advise the hypospadias repair surgery to be scheduled around 9-10 months of age. For hypospadias without chordee, it is usually a single stage surgery while for severe hypospadias or severe chordee, we choose to do a two-stage hypospadias repair procedure.

Both hypospadias and undescended testis occurring together- what does it mean?

When both hypospadias and undescended testis occur together, the diagnosis and treatment is much more complex. The most important thing to be done for these children is to investigate them for disorder of sex development or DSD. DSD is present in upto 15% of children who have both hypospadias and undescended testis. If the hypospadias is severe like scrotal or perineal hypospadias and the child has both sided undescended testis, the chances of a DSD condition go upto 50%.

So, what tests we do when we see a child with both hypospadias and undescended testis?

Any child who has hypospadias and undescended testis, should be investigated for a disorder of sex development. We are worried about conditions like mixed gonadal dysgenesis or true hermaphroditism or even severe variety of congenital adrenal hyperplasia.

Typical tests to rule out such conditions include:

1. Ultrasonogram to check for any abnormal organs inside, status of gonads.
2. Karyotype – to check for chromosomal abnormalities.
3. Hormonal evaluation – Genitogram or cystoscopy: some of these children if they have DSD also may have remnants of vagina or utricular diverticulum which can be seen only on a genitogram or a cystoscopy. MRI scan: may be needed in selected cases to rule out hemiuterus or fallopian tube.

Treatment plan for hypospadias and undescended testis

As outlined above, the first thing to do is to find out if the child has a DSD. If there is DSD, then we involve a pediatric endocrinologist and then consider assigning the gender and surgical plan starts from there.

If there is no DSD, then we prefer to do the hypospadias repair and undescended testis surgery together at around 9-10 months of age. If the undescended testis is palpable, it can be brought down in one stage via a short open surgery. If the testis is intra-abdominal then child will need a laparoscopic single or staged orchiopexy. For hypospadias, if there is no chordee or mild chordee, then we can do the orchiopexy and single stage hypospadias repair together. If hypospadias is very severe or there is severe chordee then we would need to plan for a two-stage hypospadias repair.

Summary: If your child has hypospadias and undescended testis, you must visit a qualified pediatric urologist and a hypospadias specialist. Before any surgery, a full evaluation has to be done as it has repercussions for future sexual function and fertility. But the good thing is that hypospadias and undescended testis repairs can be combined to help child get good result from both in one hospital stay whenever possible.

At Hypospadias Foundation India, we have treated thousands of children with hypospadias and some of them also had a undescended testis. A thorough evaluation and a plan for management for both was given and it worked very well for these children. Dr A.K.Singal and Dr Ashwitha Shenoy are rated as the best hypospadias surgeons in India. If you need an opinion or consult us for your child, please do write to us at hypospadiasfoundationindia@gmail.com or fill up this contact form.

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Hypospadias is a common congenital anomaly diagnosed at birth. Most of the children will need repair surgery for hypospadias and this surgery should be done by 18 months of age in a child who is born full term and is otherwise healthy. The hypospadias surgery, when done, should be carried out by an expert hypospadias surgeon. The hypospadias surgeon should be trained in hypospadias surgeries and have extensive experience and dedication to hypospadias-related work. 

As a parent of a child with hypospadias, you may be confused about how to choose the best hypospadias surgeon. Any pediatric urologist or pediatric surgeon can operate on a child with hypospadias, but every surgeon may not get the desired and best post-surgery results. Here are a few tips that will help you shortlist the best hypospadias surgeon for your child.

1. Ask your pediatrician: Pediatricians and pediatric urologists or surgeons often know each other well and work closely. Pediatricians are the first doctors to diagnose hypospadias and they can guide you to an experienced hypospadias surgeon who does lot of such surgeries and has good results for hypospadias surgery. Pediatricians often also get to see the children post-surgery and hence know the outcomes for each surgeon. Ask your pediatrician to guide you to seek the best hypospadias surgeon for your child. 
2. Connect with parents of children with hypospadias: A parent of a child with hypospadias goes through a great deal of experience when it comes to hypospadias surgery. From pre-surgery OPD visits to post-surgery care, they become experts on how to manage their child in the hospital and after surgery. New parents can discuss with other parents whose child has already completed hypospadias repair and get an honest opinion regarding the hypospadias surgeon, experience in the hospital, and their overall experience. This will help other parents gain confidence and decide what’s best for their child.
3. Search online for the best centres of expertise for Hypospadias Surgery: Most of the good centres for hypospadias treatment have a comprehensive website and a knowledge centre. Key things to look online are- qualification of the hypospadias doctor, years of experience, kind of cases they have managed, their success stories, their online reviews, the surgery videos, their publications and whether they are so good that they are training other surgeons. In the best hypospadias centres, their website will have enough information on all these points.
4. Visit your hypospadias surgeon in the OPD: Make sure you visit your hypospadias surgeon or connect with them online for a hypospadias consultation at least once before you plan the surgery. In the Outpatient department (OPD) of a hypospadias surgeon you will find many other children with hypospadias which indicates hypospadias surgery is performed regularly at that hospital. Ask your hypospadias surgeon about the cases done so far, the success rate and similar cases done in the past which will help you gain confidence in the surgeon and take a decision if he/she is the right surgeon for your child.
5. Success rate of hypospadias repair surgery: Every surgery has its own set of complications but when it comes to hypospadias the complication rates vary widely at various centers. The best hypospadias surgeon should have a success rate of more than 90% with a complication rate of under 10%.  When you visit your hypospadias surgeon do ask them about the success rate of surgery at their center. 
6. Expertise in managing complex hypospadias: Complex hypospadias such as perineal, scrotal hypospadias and redo hypospadias (hypospadias after multiple previous failed attempts) need to be managed very differently. If your child has such a hypospadias, make sure that you ask your hypospadias surgeon about their experience in managing such cases and the technique which is going to be done in your child so that you are prepared for the post-surgery period. An experienced hypospadias surgeon will be well versed in managing complex cases as well as primary ones. 

The first surgery is the best chance for a complete cure from hypospadias. Once the first surgery fails, subsequent surgeries become difficult. Hence, it is important that you do full research and choose wisely. Choosing the right hypospadias surgeon is not an easy decision for any parent. Every parent wants the best surgeon for their child. 

At hypospadias foundation, we treat more than 200 children and adults every year with hypospadias. Our dedication and expertise in hypospadias makes us one of the leading centers for hypospadias repair in the world. Do not hesitate to write to us or visit us for more information on our expert hypospadias surgeons. We will be happy to offer a second opinion or help you with understanding hypospadias treatment for your child or yourself (adult hypospadias)

 

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Hypospadias though common is still unknown to the general population. When a parent finds out that their child has a genital abnormality (hypospadias) they get very worried thinking of the child’s future, which often leads to heightened parental worries. Due to limited resources which are available in the online platform, parents do not get a clear idea when it comes to hypospadias. This blog is directed to parents who have children with hypospadias, to ease their concern and improve the knowledge surrounding hypospadias and parental worries.

1. Is surgery needed for Hypospadias? Surgery is required in hypospadias to correct the chordee, to create a urinary passage and bring the opening to the tip of the penis. The repair can be staged or single stage depending on the degree of chordee (downward bent of the penis) and severity of hypospadias. The risk of complications following surgery at our centre is less than 5%. The most common complications which we encounter are wound infection, fistula formation, diverticulum formation and meatal stenosis. An additional surgery may be required in some of these complications. Following hypospadias surgery, the cosmetic result will be similar to a circumcised penis. The meatus will be at the tip on the glans and the child would be able to pass urine in a single straight stream.
2. Anaesthesia during hypospadias surgery: Hypospadias surgeries are done under general anaesthesia. It is important that besides a pediatric urologist, a pediatric anesthesiologist doctor is available to give anesthesia safely to children. Right from dosage of medications to managing airway is very different in children when compared to adults. Hence, at Hypospadias Foundation we have 3 skilled pediatric anesthesia experts who give anesthesia for hypospadias surgery. In addition to general anaesthesia the anaesthetist will also give an injection in the lower spine (caudal anaesthesia) which gives good pain relief to children for 12 hours after the surgery. Pain relief is our priority after surgery so that children can be comfortable after surgery and don’t remember hospitalisation as a painful episode. Besides caudal anaesthesia(during the surgery), we provide adequate pain relief with analgesics for a few days post-surgery.
3. Pain after hypospadias surgery: Besides common surgical pain, which is easily manageable with pain killer medicines, two main reasons why children can develop pain in the post operative period are either due to bladder spasms or erections. Bladder spasms are controlled by a tablet oxybutynin which is started after the surgery and is continued till the catheter removal. Erection in the penis mainly occurs during early morning hours but can occur anytime in the day. Mostly the pain which occurs during erection is also managed well by the painkillers. The pain decreases significantly once the dressing and catheter are removed. However, penis continues to be sensitive for 2-3 weeks after the hypospadias repair surgery.
4. Infertility in hypospadias:  Hypospadias can cause male infertility due to various reasons. They may be due to abnormal location of the meatus, presence of chordee and low semen count. The altered opening of the urethra can cause problems in ejaculation, hence causing infertility. Presence of chordee can make sexual intercourse difficult or painful. Presence of an associated undescended testis may be associated with a low sperm count. We need to understand that not all men with hypospadias will have fertility problems. The severity of hypospadias and the success of surgical repair will ultimately decide if they will be able to father a child. Hence in men with hypospadias suffering from infertility they need to get in touch with a hypospadias surgeon because getting the hypospadias repaired will increase their chances of having children.  
5. Risk of hypospadias in future generation: The risk of hypospadias in future generations is influenced by a number of factors such as genetic and environmental factors. Some studies suggest that the risk of hypospadias may be increasing. The prevalence of hypospadias in the United states has increased by 10% from 1970 and 2000 as per the study published in the journal Nature in 2011. Hypospadias is a condition that can be inherited from the parents. If the father has hypospadias, then the risk of developing hypospadias in future generations will be 5-10%. Similarly, if first child has hypospadias, the risk in second boy is almost 5%. 
6. Cost of surgery and insurance coverage/cashless/mediclaim: 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 as cashless Mediclaim 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 issue very employee friendly mediclaim policies which cover all medical and surgical treatments for the employees and their families. Such mediclaim policies may cover all pre-existing as well as birth defects for their employees and hence hypospadias repair procedure may be covered by the insurance companies in these circumstances.

At Hypospadias foundation, we see almost 500 children and adults with hypospadias every year. The counselling in clinic, before surgery and after surgery focussing on making the families and patients comfortable, increasing their knowledge, and solving their queries regarding Hypospadias and parental worries. While there may be information available with pediatricians or on google, it is always better to consult a specialist hypospadias surgeon to have genuine answers to all the questions.

 

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Circumcision is a procedure done to remove the foreskin over the glans. The definite indications for circumcision in a child are recurrent balanoposthitis (foreskin infections), failure of local steroid therapy in phimosis and infant boys with recurrent urinary infection. Another important reason why parents choose circumcision for their child is for religious or cultural reasons.

During circumcision it is necessary to retract the foreskin completely and check for the position of the meatus. This is necessary because hypospadias can be sometimes missed and once the foreskin is excised, hypospadias repair becomes challenging. The hypospadias variants which can be missed are glanular hypospadias, MIP (megameatus intact prepuce) variant and chordee without hypospadias. Any surgeon performing the circumcision in a child should be vigilant and circumcision
should be avoided at all costs in children with hypospadias.

The reasons to avoid doing circumcision in children with hypospadias are as follows:
1. Foreskin is required for skin closure in hypospadias: Hypospadias is generally associated with deficient penile ventrally and excess foreskin dorsally. During hypospadias repair if the child has already undergone circumcision, then we may encounter difficulty in skin closure.
2. Dartos flap from foreskin is used in urethroplasty: In any urethroplasty we suture multiple layers of tissues over the urethroplasty to decrease the chance of fistula formation. This includes local tissues and dartos flap. In children who have undergone circumcision, dartos flap is unavailable to cover the urethroplasty.
3. Use of prepuce in urethroplasty: Foreskin may be required for urethroplasty in children with poor urethral plate and shallow glans groove. Prepucial onlay flap urethroplasty is a good choice in these children. This is possible only if the foreskin is available. Hence in children who have undergone circumcision this technique will not be possible.

Circumcision, though a simple procedure, has its specific indications in children. Not all boys with hypospadias need circumcision, and when deemed necessary, it should be approached cautiously. Identifying hypospadias during circumcision requires surgeons with keen observation skills to diagnose the condition accurately. The procedure should be abandoned if there’s any doubt, and the child should be referred to a specialist pediatric urologist for further management.

Do consult a specialist pediatric urologist before planning circumcision for your child if you have doubt or your doctor has told you that there may be hypospadias or chordee.
At Hypospadias foundation, we get children from all over India and from more than 25 countries all over the world in search of cure for hypospadias. At our centre we treat adults and children after multiple previous unsuccessful surgeries. Our experience clearly shows that previous circumcision makes subsequent hypospadias repair surgery difficult.

 

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Let me begin by saying: Hypospadias Repair surgery is not an easy surgery and Surgeon and Family must work together.

It takes a surgeon years to perfect the art and craft of hypospadias surgery. Every single slice of the knife, every single snip of scissors, every single stitch holds the key to a successful hypospadias repair. Despite all this, sometimes the results of hypospadias surgery may be suboptimal. The reasons for this are many. Besides an undertrained surgeon or poor equipment or expertise, sometimes the healing after hypospadias surgery is unpredictable. Even after hypospadias surgery, the penis has erections every night, putting the repair under a little bit of stress. There may be minor infection, or the child may be nutritionally deficient in micronutrients leading to poor healing. Even if these factors are controlled, individual healing is still a very variable phenomenon, leading to a small rate of complications even in expert hands. In the best hypospadias centers, hypospadias complications dip to less than 5% for distal hypospadias and less than 15% for severe hypospadias.

Any complication which happens can be disheartening for the family, the child as well as for the hypospadias surgeon. Surgeons particularly get emotionally disturbed and keep thinking about it even when they go back home and more so the surgeons who are sensitive. We as surgeons forget our 95% successes and keep carrying the burden of our complications back to our homes and our families; even the minor things haunt us. Though we may keep a strong face on the exterior, much required, inside we suffer every time something doesn’t go well. Hence, we keep striving for better and better results. Surgeon and Family must work together

Well coming back to the point- One of the most common complications of hypospadias surgery is Urethral Fistula formation. Having a complication such as fistula is not the end of the road. If the family has faith and the surgeon is experienced, urethral fistula can be managed easily with a minor second surgery in most of the cases.

I wish to share one story sent by the parents on an email to us and without any changes. The family came to us from Pune to Navi Mumbai for hypospadias treatment. Here we go:

It was indeed the happiest day of our lives when we welcomed our little bundle of joy; but soon after our son was born, the paediatrician informed us the baby is having a condition called Hypospadias with chordee albeit the degree of both the conditions was really minor, yet requiring surgery. The term Hypospadias was unheard of until then by us as well as seniors in the family. It was so devastating for us to know that the little one is already scheduled for the surgery – especially on such delicate place – before even he is a month old. Although the surgery was never life threatening and was elective in nature, as parents we were extremely nervous and anxious. Like every anxious parent, we too googled about the condition – which helped us understand better about hypospadias – before taking the next step of seeing the surgeon. Here in Pune, we did meet at least 2-3 paediatric surgeons (not the urologists or who specialise in hypospadias surgery). A senior doctor suggested 2 surgeries even for this minor hypospadias. Later we met 2-3 more doctors who suggested various methods be it keeping baby hospitalised for 7 to 10 days with medicines administered through IV lines or keeping the baby open after catheterization plus keeping his legs tied to each other in order to avoid dislodgement of catheter when he moves his legs; not to mention we were extremely petrified after meeting all these doctors as they were not at all empathetic not cordial. Not unexpectedly we were not convinced with any of the doctors as through google we already had understood that the condition can be treated as a day care surgery and babies are managed on oral medicines and in double diapers. Here, no doctor was talking about diaper and taking the baby home next day if not the same day. With due to respect to these doctors, we didn’t want to go ahead with the doctor with whom we were not comfortable with whatever little knowledge we have had gathered on this subject. The question of finding the right doctor was still there. Again, while googling we could get to know that there could be doctors who specialise as paediatric urologists and have vast experience of treating the babies / kids with hypospadias. Thanks to google and age of internet we found Dr. A.K. Singal.

 

The day we met Dr. Singal:

By the time we met Dr. Singal, our son was already 5 months old. After meeting Dr. Singal we realised why things didn’t move ahead with the previous doctors. Meeting Dr. Singal was so up to the mark as he explained the condition in detail, what he will be doing in the operation theatre and how the baby will be managed post-surgery. He was not only empathetic but also cordial and could understand what exactly the parents must be going through when their little ones must go through the surgery at very young age. His attitude was very positive. We had met the doctor we were looking for. Needless to say, we were so convinced and decided to go ahead with the surgery by Dr. AK Singal. He confirmed that both the defects would be covered in one surgery and the chances of any complications could be considered up to 2-3%. The age he suggested for the surgery was between 6 to 9 months. We took our own time to decide on the date of surgery and scheduled it when he was 14 months old. In the meanwhile, we met Dr. Singal twice with the doubts that we had. Each time he was very cordial in explaining the doubts in detail.

 

On the day of Surgery:

It was finally the day of the surgery. Nevertheless, we knew that the surgery is going to be for baby’s own good, yet our hearts were in the mouth. The doctor, as well the staff are so good that they would cater to every alarm by an extra-anxious and sensitive parent like me. The surgery went well, and the baby was brought back to the room. He was sleeping most of the day but when he opened his eyes I missed my heartbeat in the anticipation that he, now, would feel pain and the soreness; but to our surprise, he did not have any post-surgical pain on that day and any following day thereafter till the wound was healing. He was at his playful best by the next morning of surgery. He was kept in double diapers i.e. a hole was made in the inner diaper through which catheter was brought out and left to drain in the outer diaper. This method provides a cushion to the operated site, avoids catheter getting pulled accidently and makes it easy for parents to carry the child. Doctor suggested us to go home the next day, but we decided to continue for one more day for the betterment of the child. The nurses were so attentive and very cordial. After removal of the dressing and catheter, unfortunately our son caught the infection at the operated site which resulted in an extremely tiny fistula, which could not be spotted unless seen with the extreme care. This fistula was so tiny that the urine would come out from it in a drop or two. Later, as he was growing the urine output from the fistula grew to multiple drops.

 

Next appointments with the doctor:

Despite our son developed the fistula, our faith in the doctor never faded away as we were sure that doctor must have done his job with 100% care, and it was our and our baby’s fate to have the complication. The doctor never rushed and pushed us for the second surgery. He was hopeful that this tiny fistula can be healed on its own over the course of time; but the misfortune may have it, the fistula never healed, and worsened with the age by the end of year 2018. We had no choice but to put him through yet another surgery. This time as well the same protocols were followed and now our son is doing good after relatively minor second surgery.

Notes for the parents:

• Please do your research when your little one requires any kind of surgery.
• Have your questions ready so that you don’t miss any of them while you see the doctor
• Trust your vibes. Don’t go ahead with the doctor unless you’re 100% convinced.
• Get all your doubts cleared before you schedule your little one for the surgery
• Take a note of your baby’s food habits and arrange for them well in advance, especially if you are an intercity / interstate / international patient. Carry sufficient (or maybe surplus) supplies during this crucial time as the baby / child can be cranky due to change in schedule and nonetheless due to procedure.
• Carry his / her favourite toys, as that can sooth them.
• Engage them with cartoon videos
• Most importantly, however low and stressed you feel, never show baby /child your emotions and keep the spirit high. This is a tough time which too shall pass, just hang in there.
• Follow medicine schedule very promptly. Be on top of the pain. Be very punctual when to comes to medicine schedule.
• Be vigilant but don’t panic, call the hospital if you are not sure what to do?

 

Hope this story helped the families out there in some way. The lessons from the story can help both the surgeon and the family in having faith in the worst of times.

Take care and god bless.

Dr Singal

 

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Hypospadias is a common urological problem seen in children. The characteristic feature in hypospadias is excess foreskin on the front side of the penis with absent foreskin on the underside with abnormal position of meatus. The common procedure for hypospadias involves using the excess foreskin on the front side of the penis to reconstruct the urethra(urethroplasty).  Hence post urethroplasty the penis has a circumcised look.

One of the most frequent questions which Parents ask is – Can the foreskin be reconstructed and retained during urethroplasty and avoid circumcision?

Well the answer is not so straightforward. Traditionally hypospadias repair aims at bringing the meatus to the tip with circumcision as a part of the procedure. But in some cases, with newer techniques, preservation of prepuce is a possibility but not in all the cases.

Case selection is crucial when we consider foreskin preservation and reconstruction (preputioplasty) because it is associated with its own set of complications. Expectation of parents should be discussed prior to considering this procedure. The ones who do not want a circumcised look of penis for their child, we tend to offer prepucioplasty provided the procedure is possible. Hence in a few selected cases of hypospadias circumcision may be avoided. We at hypospadias foundation have operated a few cases of distal hypospadias and foreskin reconstruction(prepucioplasty) was successfully done in these children.

Here are some of the common questions/answers about foreskin reconstruction which will help the parents to know more about foreskin reconstruction in hypospadias.

1. What is the procedure of foreskin reconstruction?

Reconstruction of foreskin is called “prepucioplasty”. Following urethra reconstruction- “urethroplasty”, the prepuce is incised and closed in 2 layers- outer and inner skin separately.

2. What is the procedure done when we do not want foreskin reconstructed?

When prepucioplasty is not possible we rotate the excess foreskin from the front side of penis and use parts of it to reconstruct the urethra(urethroplasty). Following this procedure, the penis looks circumcised.

3. Which cases are ideal for foreskin reconstruction?

Children with minimal defect of foreskin on the underside of penis, distal hypospadias with no abnormal curvature (chordee) of the penis can be offered foreskin reconstruction. This procedure can be considered in parents who want to avoid circumcision for their child.

4. When do we avoid foreskin reconstruction?

Pre- operatively if the hypospadias is of moderate or severe type and if the foreskin defect is significant then we do not consider foreskin reconstruction. During the surgery if the curvature of the penis(chordee) is found to be significant we tend to avoid prepucioplasty.

5. What is the postoperative follow up in cases of foreskin reconstruction?

Following foreskin reconstruction in hypospadias, the catheter will stay for 7-10 days. During follow up, we advise the parents to gently start retracting the prepuce after 3 weeks and apply a lubricating antibiotic gel. We advise parents not to retract the foreskin at home in the initial few weeks.  Following 4 weeks after surgery, we advise application of a steroid cream for a period of 4 weeks to prevent secondary adhesions.

6. What are the complications of prepucioplasty?

Prepucioplasty is associated with its own set of complications. Early complications of prepuicoplasty involves prepucial dehiscence or incomplete retraction of the prepuce. Late complications involve secondary phimosis. Developing a fistula is also a known complication because of inability to provide dartos cover for the urethroplasty.

Here are the pre- and post-operative images of Master AP, 7-month child who underwent distal hypospadias repair with prepucioplasty.

Notice the ventral defect in prepuce is small in this case of distal hypospadias

Completed Foreskin Reconstruction (prepucioplasty)

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 in adults and children.  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 and Dr Ashwitha Shenoy are expert surgeons for Hypospadias in India. Working together as a team they have achieved excellent outcomes in primary and failed hypospadias in children as well as adults.

For appointment with Dr Singal or Dr Shenoy, kindly contact us at the contact details given below.

MITR hospital & Hypospadias Foundation, Kharghar, Navi Mumbai, India-  Call for appointments: +91-2227743558/ 27744229/ 39/69 and +91-9324180553.

MITR Clinic: C1/8 Ground floor, Sector-2, Vashi, Navi Mumbai, India – Call: +91-9324502572

 

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

The Hypospadias Foundation is an organization dedicated to disseminating thorough and credible information and providing personalized medical care for patients with Hypospadias and DSD. Caring for children with hypospadias/DSD requires a lot of commitment from both the family and the healthcare team managing these children. Our Hypospadias Guide for Pediatricians and Healthcare Professionals offers invaluable resources to support effective care and treatment strategies.

What is hypospadias and what are the types of hypospadias?

Hypospadias is a congenital condition where the opening of the urethra (meatus) is on the underside of the penis rather than on the tip. It may be associated with abnormal curvature of the penis (chordee). The different types of hypospadias, including glanular, coronal, distal penile, mid-penile, proximal penile, penoscrotal, scrotal, and perineal hypospadias, are vital knowledge for pediatricians and healthcare professionals navigating this condition. Explore our comprehensive Hypospadias Guide for Pediatricians and Healthcare Professionals for in-depth insights into diagnosis, management, and treatment strategies.

How is Hypospadias diagnosed?

Hypospadias should be suspected in a newborn when the prepuce is incomplete, the meatus is on the underside, and there is a bent penis (chordee). Ideally, a pediatrician should be able to clearly diagnose hypospadias clinically at birth. In some cases, there may be doubt, especially in minor hypospadias. In such cases, it may be good to consult a pediatric urologist or a surgeon around 3-6 months of age. Explore more insights on diagnosis and management in our Hypospadias Guide for Pediatricians and Healthcare Professionals.

When do you suspect DSD?

When should a child with hypospadias be referred to a pediatric urologist or a pediatric surgeon?

In children with isolated hypospadias, the ideal age for a surgeon to see them is around 3-6 months of age. For children with suspected DSD or small phallus or associated undescended testis, patients should be referred in the first 2-3 weeks of age itself for hormonal and DSD evaluation.

What is the ideal age for surgery for Hypospadias?

We recommend Hypospadias repair in boys between 6months to 15 months of age if they have a good weight and there is no other congenital anomaly. In some preterm babies or babies with a delayed growth, other anomalies – a second window of opportunity is between 3-5 years of age.

What are the Goals of Hypospadias surgery?

Good functional and cosmetic outcome in form of a straight penis, normally located urinary opening at tip of penis, ability to pass urine like a normal child with thick single forceful stream.

Do all Hypospadias need surgery?

Minor hypospadias like glanular hypospadias and coronal hypospadias can be left alone if the meatus is of good caliber, urine flow is in good stream & forwardly directed and there is no chordee. Otherwise, all hypospadias which are distal penile or more proximal in location or have any chordee should be repaired.

What are the tests needed before Hypospadias surgery?

For isolated hypospadias- only simple blood tests and fitness assessment are required before surgery. If there are any associated abnormalities like undescended testis then further detailed testing may be required to rule out DSD. Hormonal tests may be required if the size of the penis is small for age.

How is the Hypospadias surgery done?

Hypospadias requires a corrective surgery called Urethroplasty which involves- correction of penile curvature (Chordee) and creation of new urethra (neourethra) to the tip of penis. Many different techniques for surgery are available and a particular technique is used based on the type of hypospadias/ severity of defect. Some children may require pre-operative hormone injections to improve the size of penis and facilitate and improve surgical results.

Is the surgery done in a single stage or requires multiple stages?

The deciding factor for single or staged repair is the severity of chordee. In cases of mild chordee single stage repair is possible. Complication rates of single stage surgery are less than 10% in good centres such as Hypospadias Foundation and less than 5% may need a second surgery. Staged Hypospadias repair remains an option in very severe hypospadias and those with very severe chordee but such cases constitute less than 10% of all cases.

What is chordee correction and why is it essential?

Chordee is defined as abnormal ventral curvature of the penis. Chordee when left uncorrected or partly corrected can result in painful erection and difficult sexual intercourse. As a first step of any hypospadias surgery, chordee assessment is done after complete degloving. Based on the degree of chordee various methods are followed for chordee correction. The various methods include dorsal tunica albuginea plication, urethral plate division and proximal urethral mobilization, fairy cuts, corporotomies and in severe cases of chordee, a dermal graft for ventral penile lengthening may be required.

What is a post-surgery course and follow-up?

Most of the children are discharged on the same day in the evening after surgery. Some children with severe hypospadias or failed previous surgeries elsewhere may require 1-2 days hospital stay for antibiotic injections and pain relief. Typically, we train the parents to take care of the catheter in a double diaper fashion so that there is no urine bag hanging out. We do not advise any bed rest and children are free to walk around and play the next day of surgery.

At the time of discharge – an antibiotic syrup, analgesic (pain killer) and a medicine to control bladder spasms is commonly prescribed. Dressing is normally removed on day 7 and catheter on day 7-10 depending on the type of repair. After that a follow up visit is needed at 1 month/ 3 months and 1 year after surgery. We also like to see the children at 7-8 years and 12-15 years of age.

What surgeries are done for failed hypospadias?

In expert hands the rate of complications should be less than 10%. The common complications which can occur after hypospadias repair are urethrocutaneous fistula, urethral diverticulum, recurrent chordee and glans dehiscence. There are good techniques available to correct these complications. In children with failed hypospadias after multiple failed surgeries, oral mucosa graft urethroplasty is an option. At hypospadias foundation the results of oral mucosa graft repair are excellent with minimal complications.

Does hypospadias cause infertility?

Isolated hypospadias has not been known to be associated with infertility. Sperm counts of children who were operated on in childhood were shown to be normal. If there is associated undescended testis, then chances of infertility are higher in men with a history of hypospadias. Also, in men with chordee, intercourse may pose technical challenges, hence chordee correction is a must to provide long term normal sexual function.

Results

The Final result was very gratifying with a straight penis without any torsion. The child was passing urine in good stream in straight axis without any discomfort or pain.

About Hypospadias repair and penile torsion

Penile torsion is a condition wherein the penis is rotated or twisted on its axis. The penile torsion is more commonly to the left. Many a time penile torsion may not be detected till a circumcision is planned or foreskin is retracted.

Penile torsion may be associated with hypospadias and/or chordee (penile curvature). With hypospadias, penile torsion is mostly associated with distal penile cases.

Based on the degree of glanular rotation, penile torsion can be classified as mild, moderate, and severe. It is mild if its less than 45 degree, moderate if it’s between 45-90 degree and severe if more than 90 degree.

Penile torsion in majority of cases (>85%) is between 10 to 20 degree. If it is a moderate or severe degree of torsion, urine stream may be deviated to one side.

Surgical intervention is not always required in isolated penile torsion. The indications for surgical correction are cosmetic, functional, or sexual. When penile torsion is associated with hypospadias, it should be corrected along with Hypospadias repair or urethroplasty at the same time.

About Hypospadias Foundation

Hypospadias foundation is a centre which provides personalized and best quality care for children and adults with hypospadias. It is one of the best hospital centres in India and world for surgical treatment for hypospadias in adults and children.  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 for hypospadias are performed at MITR hospital and Hypospadias Foundation

Contact us:

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

• MITR hospital & Hypospadias Foundation, Kharghar, Navi Mumbai, India
• MITR Clinic: C1/8 Ground floor, Sector-2, VashiCall

Call for appointments: +91-2227743558/ 27744229/ 39/69 and +919324180553.

Or you can fill up this form- Contact form for Dr Singal

 

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

Dr Singal with Dr Long & Dr Zaontz

Dr Singal presented the following lectures and papers in the World Congress:

• Buccal inlay graft for failed hypospadias- Dr Singal showed technique of buccal (oral) mucosa graft inlay surgery and its results in failed hypospadias cases.
• Considerations in adult hypospadias repairs- Adult hypospadias are difficult to manage especially if the surgery done in childhood has failed. Dr Singal showed innovative surgery techniques for such adult hypospadias cases for best outcomes.
• Reimagined Byar’s flaps for staged hypospadias repairs- For hypospadias with severe chordee, it is important that the penile curvature gets fully corrected in first stage and then second stage surgery is done for bringing the urethra to the tip of penis. In expert hands the results of two stage surgery for hypospadias with severe chordee is very good. Dr Singal showed finer nuances of surgery to achieve best results to the audience.
• Parental Awareness survey for families with hypospadias: Families of children or adults with hypospadias are often not fully aware of the extent of disease and what it means in the long run. Dr Singal and his team conducted a study of 150 families to understand about their concerns about hypospadias and their knowledge level about the disease/ surgery.

Overall the three-day conference resulted in great mutual exchange of ideas and also helped younger generation of surgeons learn from eminent faculty from all over the world.

Hypospadias management has undergone big changes in last two decades. The results and outcomes of surgery have improved tremendously making hypospadias management a lesser headache for the doctor and the parents. Two decades back the results for hypospadias surgery were not so predictable and the surgeons and the family all used to be ready for mentally and financially for 2-3 surgeries and that too with suboptimal cosmetic and functional results.

Some of the things which have helped this change are:

• The newer techniques of  single stage urethroplasty (hypospadias surgery) such as onlay flaps,  Snodgrass repair and prepucial tube repairs.
• Newer and finer sutures to do the surgery such as PDS, monocryl and vicryl rapide
• Fine microsurgery instruments for doing surgery on delicate penile tissues
• Uniform use of optical magnification by surgeons while doing surgery
• Day care surgery avoiding long hospitalization and infact the whole focus is on sending the children home the same day in most cases
• Good antibiotics and  pain relief in post surgery period
• Early age at surgery – Surgery is nowadays usually done at 6-9 months of age for a child who is otherwise well
• Trained surgeons and teams dedicating time and energy towards giving a good outcome in children with Hypospadias
• Surgeons with mindset firmly towards doing a single stage repair. Mindset change has been a key catalyst towards single stage surgeries.

For a penile hypospadias whether it is mild, moderate or severe (distal, mid or proximal penile), the success rates for a single stage urethroplasty are close to 95% now; meaning that only 5% of the children require a second surgery for urethral fistula and even lesser for a stenosis. This is very heartening and gives confidence to the family as well as the doctor treating children with hypospadias. For such cases, it has become like any other surgery now, the child comes to the hospital on the morning of surgery, gets the surgery done in 1-2 hours, goes home by evening playful, active and pain free. Only thing the parents need to take care is regular medicines and diaper changes. This is certainly a huge step from 1990’s where these kids were kept admitted in the hospital for a week or ten days while they recovered after surgery.

At home children eat better, feel better, are with family and there are lesser chances of hospital acquired infections with resistant bacteria. Happiness and good food is a key ingredient for a child getting a favorable result and this component is often understated and misunderstood. Keeping the child for a prolonged duration of time in hospital only increases cost of the surgery, amount of medicines used, discomfort faced by family and also risk of hospital acquired infections.

Surgeon training in Pediatric Urology also has a great bearing on the outcomes of hypospadias repairs. With advancing experience, depth of academic and anatomical knowledge, devotion of time to hypospadias is the key to better results seen for some surgeons. It is often said that in Pediatric Urology specialty, to have good results in hypospadias surgery is often the acid test. It may be easier to excel in Laparoscopy or Endourology but still challenging to provide uniformly good results in hypospadias. The repairs and the depth of knowledge and understanding required is challenging and first few cases are unpredictable with respect to outcomes and a lot of young surgeons get disheartened and stop investing themselves into the art and science of hypospadias management. First few failures often bring out the fears and some surgeons find it difficult to continue in this unsure scenario. I still don’t know a single surgeon who never had a complication with hypospadias repairs or has stopped having complications in hypospadias. They do happen even with the most dedicated & expereinced surgeons as medical science is often an imperfect science thus lending the term “I practice medicine” but with growing volumes or experience and most importantly using the catalyst of dedication the results can quickly become very good, predictable and measurable. The complication rates/ second surgery rates become manageable and suddenly it seems enjoyable.

It is very important that a surgeon enjoys his work- it should be like meditation while doing surgery wearing magnifying loupes with all the attention solely on a 2 inch area trying to finish the nature’s unfinished business with human hands. When this happens, that is when the results are acceptable to the surgeon and the parents.

Distal Penile Hypospadias repair surgery by Dr Singal

Severe Scrotal Hypospadias- Single stage repair by Dr A.K.Singal