A 2-year-2-month-old male child presented to the Hypospadias Foundation clinic with the complaint of passing urine from the penoscrotal region since birth. On clinical evaluation in the outpatient department, the child was noted to have moderate chordee with the urethral meatus located in the penoscrotal region, consistent with Severe Hypospadias. On genital examination, the penile size was small, with a stretched penile length (SPL) of 25 mm and glans diameter (GD) of 10 mm.

Given the small penile size, an hCG stimulation test was performed to evaluate the underlying hormonal status. The test demonstrated a good increase in testosterone levels following hCG administration, but insufficient conversion of testosterone to dihydrotestosterone (DHT), suggesting impaired androgen conversion. This was suggestive of 5 Alpha reductase deficiency.

Based on these findings, the child was started on topical Dihydrotestosterone (DHT) gel therapy. The treatment was continued for two months. Following DHT gel application, there was a significant improvement in penile size, with the glans diameter increasing to 15 mm. After discontinuation of DHT therapy, hypospadias repair surgery was planned two months later to allow stabilization of local tissue effects.

Post-therapy examination revealed improvement in penile size, and the urethral meatus appeared to be located in the proximal penile region rather than the penoscrotal region.

Mast A.T., a one-year-old male, presented to the Hypospadias Foundation clinic with an abnormal ventral urinary opening on underside of penis and downward penile curvature. Clinical examination revealed a distal penile hypospadias, deficient ventral foreskin, and
ventral chordee (penile curvature).

A single-stage surgical hypospadias repair was planned, comprising of chordee correction (Orthoplasty) and urethroplasty (reconstruction of the urinary channel)

Intraoperative Procedure

The procedure commenced with a 5-0 Prolene stay suture on the glans for traction. Local anaesthesia (Xylocaine with adrenaline) was infiltrated at the marked incision sites. Following the initial incision and complete degloving of the penis, an artificial erection test was performed to assess the degree of curvature.

 Chordee Correction: A curvature of less than 30 degree was noted. This was corrected via Tunica Albuginea Plication (TAP) on the dorsal aspect (upper part) of the penis, opposite the site of maximum curvature. A repeat artificial erection test confirmed complete correction of the chordee.

 Urethroplasty: The glans wings were marked, incised, and widely mobilized. A midline incision was made in the urethral plate to increase its width (TIP – Tubularized Incised Plate technique). The neo-urethra was constructed in two layers:

o Layer 1: Continuous subcuticular sutures.
o Layer 2: Interrupted sutures.

 Waterproofing: A preputial dartos flap was raised and transposed over the urethroplasty site to provide a vascularized waterproofing layer, significantly reducing the risk of a fistula (leak).

 Completion: Glansplasty was performed to reconstruct the glans. The skin was closed in two layers using 6-0 PDS and 6-0 vicryl Rapide.

Postoperative Outcome and Follow-up

The repair was stented using a 7 Fr infant feeding tube, with the new meatus successfully positioned at the tip of the glans.

 Day 7: The catheter and dressings were removed. The patient demonstrated a strong, straight urinary stream with no associated pain.

 Healing: The surgical site healed by primary intention without complications (e.g., hematoma, infection, or dehiscence).

 1-Year Follow-up: The patient remains asymptomatic with excellent functional and cosmetic results.

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

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

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

Master VM, a 1.5-year-old boy with severe hypospadias, was brought to the clinic from Surat. On examination, the urinary opening was scrotal in location. There was significant chordee also. The final diagnosis thus was Scrotal Hypospadias with chordee. Everywhere else, he had been advised a staged urethroplasty requiring three surgeries. A single-stage urethroplasty was planned for the child with severe hypospadias. As the first step, the penis was degloved to obviate the chordee. Even after degloving, significant chordee was still seen. A 12 O’clock tunica albuginea plication stitch was taken, and the penis was straightened. The chordee correction test showed no residual chordee.

A decision was made to make a tube from the dorsal prepuce and use it as a new urethra by rotating it towards the underside of the penis. This is called a single-stage “prepucial tube urethroplasty,” one of the complex repairs for severe hypospadias.

A prepucial flap was outlined and was harvested with good dartos blood supply. This was then brought ventrally and sutured to midline tunica albuginea with PDS to lay a base for tubularisation. Then this flap was tubularised over a 7Fr catheter as a new urethra Glans repair and a new urethral opening was made. The prepuce was split in midline and brought towards underside to cover the new urinary passage.

B.Q., a 7-month-old baby, was brought to our clinic with an abnormal-looking penis and passage of urine from the underside of the penis. On examination, he had a scrotal hypospadias with mild chordee (an abnormality where the penis is bent downwards).

A boy with scrotal hypospadias – Transverse Island Onlay Flap urethroplasty was planned for corrective surgery. This specific case involved a single-stage urethroplasty, for which many different techniques are available. The exact technique in this case was a long transverse island flap urethroplasty.

This is the appropriate age (6-9 months) for such surgeries as the final results are very good both cosmetically and functionally at such a young age. We chose to give two doses of hormones before surgery to improve the outcome after single-stage surgery.

Since this was a very severe hypospadias, the chances of failure were higher. We decided to harvest a tunica vaginalis flap for second-layer coverage of the repair (see pictures). The tunica vaginalis is a covering of the testis and provides good second-layer coverage in such severe cases, improving the outcomes manyfold.

The baby was taken up for surgery and required only a one-day stay in the hospital. The dressing was removed on day 5 and the catheter on day 12. There was no fistula or dehiscence.

At the 3-month follow-up, he had a normal-looking circumcised penis with a urethral opening at the top of the glans.

S.J., an 8-month-old baby, was brought to Dr. A.K. Singal’s Hypospadias clinic with an abnormal-looking penis and passage of urine from the underside of the penis, almost near the scrotum. On examination, he was diagnosed with a condition called Penoscrotal Hypospadias with mild chordee (an abnormality where the penis is bent downwards). The baby was planned for a corrective hypospadias surgery called SINGLE STAGE URETHROPLASTY, which can be done by multiple techniques, including the Transverse Island Onlay Flap urethroplasty. This technique is particularly suited for cases like a boy with severe hypospadias.

The exact technique in this case was a long Tranverse Island flap urethroplasty. This is the appropriate age (6-9 months) for such surgeries as the final results are very good both cosmetically and functionally at such a young age.

The baby was taken up for surgery and he required only one day stay in the hospital. The dressing was removed on day5 and the catheter on day12.

At 3 months follow-up he has a normal looking circumcised penis with a urethral opening at the top of the glans

Facts about Hypospadias

• Hypospadias is one of the most common pediatric urological anomalies worldwide.
• The correct age for hypospadias repair surgery is between 6-9 months.
• Most of the hypospadias can be corrected with a single stage surgery, rarely if the penis is too curved (chordee) or the skin is short or there is an associated disorder of sex development, a two or a three stage hypospdias repair may be required.
• The success rate of Single Stage Urethroplasty in correctly chosen cases is more than 95%.
• Most common problems after hypospadias surgery procedure (5%) are infection and formation of a urethral hypospadias fistula requiring a second surgery.

A.S., 9 months old child was brought with abnormal curvature of penis and abnormal urinary opening- a condition called hypospadias (means urinary opening on downside of penis). The abnormal curvature is called chordee. On examination – urethral opening was situated on the underside of penis (Coronal Hypospdias) and the terminal part of urethra was very thin and abnormal for whole length of penis. This is called hyoplastic urethra. These types of hypospadias may deceptively look mild as the thin distal urethra often needs to be excised and the hypospadias becomes a severe one. The child was planned for a single stage hypospadias repair by Dr A.K.Singal (Hypospadias Specialist)

During hypospadias surgery, hypoplastic urethra was excised and the penis was straightened (chordee reapir). A flap was made from the excess skin on the upper side of penis – this technique of Single Stage Urethroplasty is called Transverse Island Flap Urethroplasty. The flap was rotated towards the underside of penis for making a new urinary pipe. The baby was discharged the next day after surgical correction of hypospadias and double diaper was used for draining the catheter.

Dressing was removed five days after single stage urethroplasty and the catheter was removed after 10 days in clinic.

At 3 months follow-up the penis has healed well and now looks like a normal circumcised penis indicating a successful hypospadias surgery

Facts about Hypospadias

• Hypospadias is one of the most common anomalies worldwide.
• The correct age for corrective surgery is between 6-9 months.
• Most of the hypospadias can be corrected with a single stage surgery, rarely if the penis is too curved (chordee) or the skin is short or there is an associated disorder of sex differentiation, a two or a three stage surgery may be required.
• The success rate of Single Stage Urethroplasty in correctly chosen cases is more than 95%.
• Most common post-op problems (5%) are infection and formation of a fistula requiring a second surgery.
• Link to Hypospadias foundation
• Link to FAQ’s about hypospadias

A.S., 9 months old child was brought with abnormal curvature of penis and abnormal urinary opening- a condition called hypospadias (means urinary opening on downside of penis). The abnormal curvature is called chordee. On examination – urethral opening was situated on the underside of penis (Coronal Hypospdias) and the terminal part of urethra was very thin and abnormal for whole length of penis. This is called hyoplastic urethra. These types of hypospadias may deceptively look mild as the thin distal urethra often needs to be excised and the hypospadias becomes a severe one. The child, a boy with distal penile hypospadias, was planned for a single stage hypospadias repair by Dr A.K.Singal (Hypospadias Specialist).

During hypospadias surgery, hypoplastic urethra was excised and the penis was straightened (chordee reapir). Incision was given in the urethral plate in the midline and urethroplasty done which is called Tubularized Incised Plate Urethroplasty. The baby was discharged the next day after surgical correction of hypospadias and double diaper was used for draining the catheter.

Dressing was removed five days after single stage urethroplasty and the catheter was removed after 10 days in clinic.

At 3 months follow-up the penis has healed well and now looks like a normal circumcised penis indicating a successful hypospadias surgery.

Facts about Hypospadias

• Hypospadias is one of the most common anomalies worldwide.
• The correct age for corrective surgery is between 6-9 months.
• Most of the hypospadias can be corrected with a single stage surgery, rarely if the penis is too curved (chordee) or the skin is short or there is an associated disorder of sex differentiation, a two or a three stage surgery may be required.
• The success rate of Single Stage Urethroplasty in correctly chosen cases is more than 95%.
• Most common post-op problems (5%) are infection and formation of a fistula requiring a second surgery.
• Link to Hypospadias foundation
• Link to FAQ’s about hypospadias