Mast B.E, 14-year male from Mumbai had undergone two unsuccessful hypospadias repairs at another hospital in the past. He presented to Hypospadias Foundation with complaints of passing urine from two sites, which is from the tip and from the distal penile region. On clinical examination, there was an eccentric subcoronal fistula with a thin glans bridge separating it from the glanular meatus. There was some residual skin on the dorsal side. The urine stream was spraying as shown in the photo below

He was planned for single/ two stage repair depending on the degree of chordee, status of native urethra and quality of urethral plate. Cystoscopy was noted to be normal. Chordee assessment showed no residual chordee. The thin glans bridge between the meatus and the fistula was divided. The urethral plate was noted to be wide with no scarring. Considering all the above factors he was planned for single stage repair – simple tube urethroplasty or Glans Approximation Procedure was decided.

Stay suture was taken on the glans with 4-0 prolene. Complete degloving was done. Artificial erection test showed no residual chordee. Glans wings were marked and raised. Urethroplasty was done by continuous inverting subcuticular sutures with 6-0 PDS over 8Fr infant feeding tube. Second layer closed over the urethroplasty with local tissues with 6-0 PDS interrupted sutures. Right dartos flap was raised and sutured over the urethroplasty with 6-0 PDS. Glansplasty was done with 5-0 vicryl. Unhealthy skin was excised; edges were freshened and closed in 2 layers with 6 0 PDS and 6-0 vicryl rapide.

Single stage Redo hypospadias repair in a child with recurrent distal penile fistula

3-and-a-half-year-old male was diagnosed with penoscrotal hypospadias at birth. He underwent single stage urethroplasty at 1 and half year of age at another centre. Following the urethroplasty, he developed urine leak from the distal penile region. A second surgery was done to close the fistula. Unfortunately, the fistula recurred. Parents were disappointed and visited hypospadias foundation for treatment of their child.

We examined the child in the OPD and noted that there was a small fistula in the distal penile region with a normal meatus on the glans. He was passing urine mainly from the meatus (95%) and with a leak from the distal penile region (5%).

At hypospadias foundation, after examination we counselled the family for surgical repair which would be dependent on the quality of urethra, any residual chordee and blood supply to the tissues. While we aim to do a single stage repair for such cases, in some cases a decision to do a staged repair may be made during surgery.

On cystoscopy, a ledge was noted at the junction of normal urethra and reconstructed urethra. On artificial erection test, there was no residual chordee. The tissues were also healthy around the fistula. The findings were in favour of single stage fistula closure; hence we proceeded with the same.

Fistula site was marked. Local anesthesia with adrenaline was infiltrated at the marked site. Incision was given around the fistula site. Fistula site was mobilized all around and tract was completely excised. Fistula site was closed in 2 layers with 6-0 PDS over a 7Fr infant feeding tube. Local flap along with underlying dartos tissue was raised and sutured over the fistula site to decrease the risk of recurrent fistula formation. Skin was closed in 2 layers with 6-0 PDS and 6-0 vicryl rapide. The ledge in the distal urethra was incised. Post surgery, the dressing along with the catheter was removed on post operative day 7. Post catheter removal, he was passing urine in single straight stream with no pain or leak.

Hypospadias remains one of the most common urological anomalies in children. With almost 1/150 boys across the world born with hypospadias every year, there is a large number of children with hypospadias who do not reach the right hypospadias doctor. Failed hypospadias surgery can compound these challenges, highlighting the importance of seeking specialized care. Hypospadias is a complex anomaly, and there are many variations possible in anatomy which dictate the type of surgical repair being done and results thereof.

Results and complications of hypospadias surgery depend on the experience of the hypospadias surgeon and his interest in managing the condition. While some hypospadias surgeries fail due to failure on the part of the surgeon to select the proper technique of repair, others fail due to unknown reasons and it is difficult to go back and check whatever the reason may be. Unfortunately the time only moves one way and that is forward.

The common type of failures or complications seen in hypospadias surgery are:

1. Urethral fistula- leakage of urine from somewhere other than main hole- 2-3 streams may be seen. Fistula formation is the most common complication of hypospadias surgery.
2. Stricture or stenosis: new passage may become tight leading to narrow stream, painful urination and straining to pass urine. This can be at the tip- meatal stenosis or somewhere down in the new passage.
3. Curvature: Sometimes surgeon doesn’t correct the chordee fully because of which there is residual chordee. Remember if the chordee is not corrected fully in the first surgery, there is always a chance of failure of surgeries and future complications. Hence, chordee correction is the most important step in the hypospadias surgery.
4. Diverticulum: here the new urethra balloons up leading to visible swelling in the penis while passing urine. This can lead to local and urine infections as well difficulty in passing urine.
5. Dehiscence: Sometimes the repair gives way completely- this can be at the level of glans (glans dehiscence) or partial or complete dehiscence
6. Penile torsion: If the penis is rotated around its axis, it is called penile torsion. Sometimes the penile torsion is present before the surgery or it can happen post-surgery also due to complication of the hypospadias surgery itself.
7. Poor cosmetic result: If there is kin level sinus formation, uneven tags or even penile skin shortening, this can lead to poor cosmetic outlook.

How second opinion can help for a child or adult with failed hypospadias

Hypospadias is one clinical condition where we do not need any complicated tests or examination to determine if the child had a success of the hypospadias surgery or not. If the child is passing urine from the tip of penis, in a single, straight, thick stream comfortably and the erections are straight- they know that the surgery has been successful.

Often the primary surgeon may be not able to manage the complication, may not be an expert in managing failed hypospadias, or may not be able to think through the complication roadmap due to a mental roadblock. In such situations, an expert neutral second opinion from an experienced hypospadias surgeon may help significantly. A new line of treatment or a fresh perspective may help in finding the right solution. At Hypospadias Foundation, we often see cases where the first surgeon has tried 3-4 surgeries, sometimes even 6-7, and they have not worked; clearly, a new approach should have been taken to give a good result. If you’re dealing with the aftermath of failed hypospadias surgery, trust in our expertise for comprehensive evaluation and personalized solutions.

How to take a second opinion for hypospadias

You can just fill-up this form (Contact form for Hypospadias) or send an email to hypospadiasfoundationindia@gmail.com or communicate via whatsapp with Dr Rajkumar – +919821261448. It is best to send pictures of penis, a short video of child passing urine and pictures of previous surgery records. A short summary in a word document also helps us in understanding the issue. We typically get back with an opinion within one week.

Payment for second opinion

Most of the times if it is a basic opinion & short straightforward case, Dr Singal discusses with Dr Rajkumar and then Dr Rajkumar sends an outline of suggested approach via email. There are no charges for a basic second opinion. Dr Rajkumar has been working and managing all remote consults at Hypospadias Foundation for more than 10 years and has managed more than 2000 cases with Dr Singal.

At other times if the parents wish to speak to Dr Singal or the case requires and extensive review which can’t be done in a short while, then it is time commitment from Dr Singal. Such consultations are chargeable and done on phone or skype. Typical charges vary from 1500 INR to 100 USD.

Can second opinion be given without in person examination?

With the availability of good pictures, videos, medical records and reliable history- a very reliable second opinion can be given for hypospadias. Very rarely, the case is too difficult or needs a physical examination, in such cases we let the family know about this in advance.

Be rest assured that a good outcome after treatment at Hypospadias Foundation in India is a common and mutual goal for us and the family. We get children from all over the world who travel far and wide to India for finding a cure and best results for their child’s failed hypospadias. And we give our best care and treatment to all such families.

Dr A.K.Singal, Pediatric Urologist India

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

Watch Surgery Video for Failed Hypospadias by Dr Singal

Like every other surgery, hypospadias correction surgery has its own risks, complications and failures. Inspite of the best intentions and efforts of the parents and the treating hypospadias surgeon, still the results may be sub-optimal after the first surgery. Though at the end of hypospadias surgery in OT it may seem that the surgery has gone very well, sometimes there may be minor complications which necessitate a second surgery for hypospadias in some children. The rate of second surgery for a complication or failure of first hypospadias surgery decrease with the expertise and experience of the hypospadias surgeon but it is never zero and that is an important thing for the parents and families to understand.

When the first surgery for hypospadias fails, parents get very disturbed and start looking for more information on why it happened and the solutions and second opinion for hypospadias to help fix the problem. Most of the times, the primary surgeon may be the best person to solve the problem but sometimes the complication may be severe and in such cases the patient should be referred to a centre of excellence in hypospadias surgery.

While minor problems like fistula or cosmetic issues can be treated easily with as second minor surgery- major complications of hypospadias surgery such as urethral breakdown, dehiscence, urethral diverticulum or stricture may require more complicated or even a staged repair with grafts. Hence, the dictum- that first surgery for hypospadias is the best surgery- further surgery if the first one fails is always more difficult and challenging.

At Hypospadias Foundation, we regularly receive kids and adults from all over India and other countries who have had a failed hypospadias surgery elsewhere. Families request for a second opinion for the hypospadias treatment and we advise them comprehensively. Some of these cases really benefit from the specialist care offered by a dedicated hypospadias team.

Case Story

Master A.G., a 3 years old boy, resident of Nagpur, underwent a surgery for a proximal penile hypospadias surgery at a hospital in Vellore. Unfortunately, the healing was not optimal and the whole repair had a breakdown. After 6 months of previous surgery, the family wrote to us and visited us at our centre in Kharghar, Navi Mumbai. On examination, the child has proximal penile meatus with mild chordee. There was a remnant of foreskin (prepuce) on the underside of penis. There was no foreskin left on the topside of penis. We explained to the parents that this may require a two stage repair but we will try out best to make a flap from the residual foreskin and do the surgery in one stage.

Finally after pre-surgery tests and fitness assessments, we took the child for redo-hypospadias surgery. We could make a nice onlay flap out of the foreskin remnant by carefully dissecting the blood supply and preserving the supply to this flap skin. The flap was used to make the new urethra in one stage as it can be seen in the video below.  The surgery took about 3 hours and the child was allowed feeds four hours after surgery. The dressing was removed after 7 days and catheter after 10 days. The hypospadias site healed very well and the child was examined again after 1 month. He was passing urine well in a single stream from the tip of penis. Now, 6 months after hypospadias repair, A.G. continues to do well and his parents are very happy and we are also overjoyed to achieve a good result in this challenging failed hypospadias case. The detailed hypospadias surgery video can be watched by clicking below. Besides the story mentioned here, the video below shows another child story from Raipur, Chattisgarh where the first surgery resulted in a penile torsion and a large fistula. The child underwent a successful single stage surgery at Hypospadias Foundation:

Watch Video of Failed Hypospadias surgery by Dr A.K.Singal

Hypospadias remains the most common urological abnormality affecting more than 1 lakh kids in India alone (based on incidence of 1/150 in newborn boys). Leaving aside very minor hypospadias without chordee- almost 70-80% of these require hypospadias treatment in form of repair surgery in early childhood.

For a child with Hypospadias, the first surgery is always the best surgery but still there can be complications and failure even in expert hands though complications are much less if operated by a surgeon or a centre where there is a focused practice in treating children with hypospadias. Literature and experts suggest that if a hypospadias surgeon is doing more than 50 hypospadias repairs in a year, then his results will be better and more predictable as compared to a general pediatric surgeon or a urologist who does only 10-20 hypospadias repairs in a year. Once a hypospadias surgery fails, then the next surgeries become more difficult and result more unpredictable. The failure rate of hypospadias surgeries vary from 5% to 50% depending on the type and severity of hypospadias in general centres and less than 10% in centres where hypospadias surgeries are done by expert hypospadias surgeons on a day to day basis.

Case details

Master A.P. was born with a distal penile hypospadias and underwent first surgery in Ahmedabad at the age of 6 years. Unfortunately, the surgery failed and he started passing urine from the same place on the underside of penis- a fistula. The new urinary passage through the head of the penis got tight and closed off. The surgeon tried to open it many times by catheter insertion but it failed. Coupled with failed hypospadias, the child also had an unsatisfactory cosmetic appearance in form of bunching of skin on underside of penis. With this situation they contacted Dr A.K.Singal, Pediatric urologist and expert Hypospadias surgeon at Hypospadias foundation in Kharghar, Navi Mumbai when the boy was ten years of age. After examining and confirming that the whole urinary pipe will have to be remade from distal penile region to the tip of penis (glans), Dr Singal advised a Onlay island flap repair for which the flap would be raised from the nearby bunched up skin. This repair is technically challenging because of previous failed hypospadias surgery but this was the only chance for the boy to have a single stage repair. The surgery for failed hypospadias was finished in 2 hours and A.P. was ready for discharge the next day but since they had travelled all the way from Gujarat, they decided to stay for 7-8 days in Navi Mumbai. The catheter was removed on day7 and he passed urine well from the tip. For the first one month after surgery, there were some chances of new opening getting tight, hence we taught the boy to insert a small catheter just 1cm into the new opening with an antibiotic ointment. The penis healed well in next 3 months and he has remained free of all symptoms now for last 5 years. At 15 years of age and after his 10^th standard exams, A.P visited us and had a big smile on his face. He is looking forward to higher education and he shared with us his dreams and further education goals. We plan to see him again one last time at 18 years of age. His penis growth and his functional & cosmetic outcome has been excellent so far.