Uncategorized Archives - Hypospadias Foundation

August 08 2025

A closer look at severe chordee correction in an adult by 24 dot plication

25-year-old adult presented to the Hypospadias Foundation OPD with complaints of severe curvature of the penis. There were no urinary complaints. He also that the curvature has worsened over time. On examination, there was severe ventral curvature (downward bending) of the penis. Meatus was located on the glans and was normal in location. No plaques were felt on palpation. Ultrasound doppler of the penis was done which was normal. He was counselled for surgery. Surgery was planned in single or two stage depending on the degree of curvature and the ventral urethral calibre.

Picture 1: Severe curvature of the penis noted on erection

Picture 2: Pre-operative assessment showed normal location of the meatus. Second image shows marking for degloving

Surgery was started by taking a stay stitch on the glans with 4-0 prolene. Marking of the deglivng incision was done and local anaesthesia lignocaine with adrenaline was injected at the marked site. Complete degloving was done. Chordee was assessed by artificial erection test and more than 60-degree chordee was noted. Since the penile length was good and urethra was not appearing short or taut, we decided to proceed with dorsal plication procedure to correct the chordee.

Buck’s fascia along with neurovascular bundle was raised on the dorsal side starting laterally and upto the midline. Chordee was reassessed and exact site of curvature was marked. 24 dots(12 dots on either side) were marked. 4 dots proximal and 8 dots distal to the site of maximum curvature. Longitudinal plication sutures were placed at these sites with 4-0 prolene involving full thickness tunica albuginea. Chordee was reassessed and there was no chordee. Chordee was completely corrected by these plication sutures. Buck’s fascia was closed on either side with 6-0 PDS. Circumcision was completed and skin rearranged and closed in 2 layers with 6-0 PDS and 5-0 vicryl rapide. 12Fr silicone catheter was placed per urethra and dressing was done. Catheter was removed after 7 days. Follow up at 6 months after surgery, there was no chordee and the erection was straight.

Picture 3: Complete degloving done and artificial erection test done which showed more than 60-degree chordee.

Picture 4: Neurovascular bundle raised on both sides upto the midline. Marking done, plications sutures placed, held and artificial erection test done. No chordee noted

Picture 5: 24 dot plication completed and circumcision done

Picture 6: Penile erection straight 6 months after surgery

Picture 7: Cosmetic result 6 months after surgery

Severe ventral chordee in adults: Diagnosis and management

Chordee is characterized by curvature of the penis which is noticeable only during penile erection. This is congenital (present at birth) but can be missed in childhood and can present with challenges in adulthood potentially causing discomfort, affecting sexual function and can also have psychological implications impacting self-esteem.

In chordee, there is noticeable bend in the penis during an erection which can be downward, upward or sideways. It can cause pain or discomfort during erection or sexual intercourse. Surgical correction is the only effective method of chordee correction in adults. The goal of the surgery is to straighten the penis and restore normal function. Chordee correction can be done by dorsal plication or ventral lengthening procedure. Ventral lengthening procedure is done if there is short urethra which contributes to the penile curvature. If the urethra is normal with good penile length, then dorsal plications are preferred.

In the above-mentioned case, the penile length was good, and the urethra was normal hence we proceeded with dorsal plication. In this procedure multiple (16 or 24) non absorbable fine sutures are strategically placed on the convex side of the penis. These sutures are placed in pairs and in parallel fashion to create plications in the tunica albuginea. Neurovascular bundles are carefully raised before placing the plication sutures.

Important note for adult chordee

It is essential for adults considering chordee correction to have a thorough evaluation by a hypospadias specialist who specialized in penile reconstructive surgery. The surgeon will assess the type and degree of curvature, discuss the case and recommend the most appropriate surgical technique whether plication or a staged procedure.

At hypospadias foundation, we get adults and children from all over the world in search of treatment for hypospadias. We provide support and information for children, adults and their families affected by hypospadias. Dr Singal and Dr Shenoy are deeply devoted to creating awareness and helping patients get the right treatment for hypospadias be it primary, redo or adult hypospadias. Children and adults from more than 25 countries visit our hypospadias foundation in search for cure and are cured of hypospadias.

Dr A K Singal is a highly experienced surgeon and regarded as the best hypospadias surgeon in India and in the world. He has dedicated his life towards treating children and adults with hypospadias. His expertise in this area has helped us achieve excellent outcomes in adults and children with hypospadias.

Dr Ashwitha Shenoy is an expert pediatric surgeon with special interest in pediatric urology and hypospadias. Both Dr Singal and Dr Shenoy work together to give

July 07 2025

Two stage repair of deceptive distal penile hypospadias with hypoplastic urethra and severe chordee

6-year male from Kerala presented to the Hypospadias Foundation clinic with complaints of passing urine from distal penile region associated with downward curvature of the penis (chordee). On examination, meatus was in distal penile region, but the urethra was thin till the proximal penile region. The stretched penile length (SPL) was 40mm and glans diameter (GD) was 12.5mm. In view of small glans diameter, he received two doses of injection testosterone in the pre surgery period which were given 1 month apart. Following the two doses, the stretched penile length improved to 35mm and glans diameter to 15mm.

He was planned for hypospadias repair and the family was counselled for single or two stage repair based on the degree of chordee.

The surgery was started by complete degloving which means the penile skin was completely taken down preserving its blood supply. After degloving, the chordee was assessed by artificial erection test. Here in this case after complete degloving, artificial erection test showed chordee of more than 45 degrees. This was because of the hypoplastic (underdeveloped) tissues on the underside of the penis. We decided to divide the urethral plate and mobilise the urethra. Spongiosum was raised on the sides first, urethral plate divided at coronal level and urethra mobilised till penoscrotal junction to fully evaluate the chordee. Chordee was reassessed and there was persistent chordee of more than 45 degrees. Site of maximum curvature was marked on the ventral side (underside of the penis) and three corporotomies were made by placing horizontal incisions over the tunica with middle incision at the site of maximum curvature. Chordee was reassessed and there was still significant chordee necessitating a ventral penile lengthening procedure called as dermal graft. The central corporotomy incision was deepened to full divide tunica and then cavernosal tissue was mobilised from tunica on all sides. A skin ellipse was harvested from the inguinal region, de-epithelized, and defatted to create a dermal graft. This dermal graft was sutured at the site of tunical defect with 6-0 PDS interrupted sutures. An artificial erection test following dermal graft revealed no chordee.

Once the chordee was corrected, the proximal urethra was sutured in the proximal penile region with 6-0 PDS. Glans wings were raised. Byars flap was created. Byars flap involves division of the dorsal prepuce in the midline and then rotation to the underside of the penis to cover the whole underside of the penis from glans till all around the meatus.

Picture 1: On clinical examination, the meatus was in the distal penile region with thin urethra till the proximal penile region. Surgery was started by complete degloving

Picture 2: Artificial erection test showed chordee of more than 45 degrees

Picture 3: Urethral plate divided, mobilised and chordee reassessed. More than 45 degrees chordee noted

Picture 4: Three ventral corporotomies given and chordee reassessed, persistent chordee of more than 30 degrees noted, hence planned to go ahead with ventral lengthening procedure

Picture 5: Deep corporotomy given at the site of maximum curvature and tunica incised, dermal graft harvested from the right inguinal region

Picture 6: Dermal graft sutured at the site of tunical defect. No chordee noted after dermal graft.

Picture 7: Dorsal prepuce (foreskin) divided in the midline and flaps rotated to cover the underside of the penis

Second stage of Hypospadias Repair:

After 6 months of first hypospadias surgery, the child was taken up for second stage urethroplasty. We checked chordee again before starting the urethroplasty (urethral reconstruction) and the penis was completely straight. The prepucial flaps which were done in first stage had healed very well. The flaps were wide and supple. 15mm wide incision was marked on the flaps and, local anaesthesia was infiltrated at the marked site and incisions were deepened till the corpora. Urethroplasty was done over 7Fr Infant feeding tube in two layers with 6-0 PDS absorbable sutures. Dartos flap was harvested from both sides and sutured over the entire urethroplasty. Glans wings were raised. Distal urethroplasty and glansplasty was done, and a new meatus was created on the glans. The dressing in the post operative period was changed on post operative day 7 and catheter was removed on post operative day 12. Child was passing urine through the new opening in a good stream.

Picture 8: Prepucial flaps 6 months after stage 1 were healed very well. Flaps were wide and supple. Artificial erection test done before urethroplasty done showed no residual chordee

Picture 9: 15mm wide flaps marked and incised.

Picture 10: Urethroplasty done over 7Fr Infant feeding tube, dartos flap raised and sutured over the urethroplasty and glansplasty done

Picture 11: Completion of urethroplasty and follow-up at post operative day 12

Picture 12: Urine stream following catheter removal

Distal penile hypospadias with severe chordee (Deceptive hypospadias)

In some cases of hypospadias, the urethral opening is not only in an abnormal location but also the urethra can be underdeveloped or hypoplastic. Hypoplastic urethra is characterized by thin, underdeveloped, paperlike quality of urethral plate and the existing distal urethra. While the meatal opening may be near the tip, the presence of a hypoplastic or underdeveloped urethra indicates a more complex form of hypospadias, even if the urethral meatus appears relatively distal. This is often associated with chordee which contributes to the overall complexity of the hypospadias.

The hypospadias repair in hypoplastic urethra is more challenging. This thin urethra does not have enough robust tissue to create a new functional urethra. Using this thin urethra in reconstruction can lead to complications such as fistula formation, stricture, diverticulum formation or dehiscence.

The surgical management in hypoplastic urethra often requires specialized techniques. Degloving in these cases must be done carefully because of higher chance of injury to the urethra due to its paper-thin consistency. The type of surgical repair in cases with hypoplastic urethra is decided based on the degree of chordee. If the chordee is not significant and if single stage repair is planned, then either the thin urethra must be laid open before staring the urethral reconstruction or spongiosa around the thin urethra has to be mobilized and sutured over the thin urethra which is called as Spongioplasty.

For severe cases, like in the above-mentioned case with significant chordee and extensive hypoplastic urethra, two stage repair may be necessary. In the first stage, the penis is straightened and prepucial flaps are created. In the second stage which is 6 months after stage 1, the flaps are tubularized to form the new urethra.

Long term follow in cases of hypoplastic urethra is necessary because complications like stricture can develop years after hypospadias repair surgery. Hence these complex cases of hypoplastic urethra with hypospadias should be performed by an experienced hypospadias surgeon.

At hypospadias foundation, we have operated many cases of hypospadias with hypoplastic urethra. Each case is thoroughly examined in the preoperative period, carefully degloved during the surgery, meticulously assessed and hypospadias repair is done considering factors such as degree of chordee, severity of hypoplasia and quality of urethral plate. This has helped us achieve success rate of more than 95% even in the most complex cases.

The team at Hypospadias Foundation has two experienced hypospadias surgeons. Dr A.K Singal is considered the best hypospadias surgeon in India and the world and has a special expertise in managing complex hypospadias cases. His profound anatomical knowledge, meticulous surgical skill and an unwavering commitment to restoring both form and function in hypospadias has transformed various lives.

Dr Ashwitha Shenoy is an expert hypospadias surgeon who along with Dr Singal has dedicated her life to treating children and adults with hypospadias. Their dedication extends beyond the operating room, offering compassionate guidance and hope to families navigating a challenging diagnosis.

July 07 2025

Staged repair of Midpenile hypospadias with severe chordee

2 year 6 months male child came to Hypospadias Foundation from Nepal with complaints of passing urine from the mid penile region associated with abnormal ventral curvature of the penis. Parents were looking for an experienced hypospadias surgeon hence they delayed the surgery till 2.5 years of age. On examination, the meatus was in the mid penile region with poor urethral plate. He was planned for hypospadias repair, and we counselled the family that whether the surgery would be in 1 stage or two stages will be decided depending on the degree of chordee during surgery.

At the start of hypospadias surgery, the entire penile skin was taken down all around till the base of the scrotum, a step known as complete degloving. Chordee was assessed after complete degloving. Chordee was noted to be more than 45 degrees. This was because of deficient tissues on the underside of the penis. We made a horizontal incision on the underside of the penis at the site of maximum curvature and divided the urethral plate. After division of the urethral plate, the proximal urethra was mobilized. Chordee was reassessed and there was persistent chordee of more than 30 degrees noted. Site of maximum curvature was marked on the ventral side. Three Corporotomies were done by placing horizontal incisions ventrally over the tunica with middle incision at the site of maximum curvature. Chordee was reassessed and less than 30-degree chordee was noted. Complete Chordee correction was achieved by tunica albuginea plication at 12’o clock position on the dorsal side. Artificial erection test showed straight penis.

After that the foreskin(prepuce) was divided in the midline and rotated to cover the underside of the penis- a step known as Byar’s flaps. This hairless prepucial skin which is now on the underside of penis will be utilized in the second stage for urethroplasty.

Picture 1: On clinical examination, the meatus was at the mid penile region with severe chordee

Picture 2: Marking done for degloving and complete degloving done

Picture 3: Artificial erection test was done which showed chordee of more than 45 degrees and hence urethral plate division was done

Picture 4: Persistent chordee of more than 30 degrees hence three ventral corporotomies given

Picture 5: Less than 30 degrees chordee noted after three ventral corporotomies hence 12’o clock dorsal tunica albuginea plication done. No chordee after dorsal tunical plication

Picture 6: Dorsal prepuce(foreskin) divided in the midline and rotated to cover the underside of the penis

Second stage of Hypospadias Repair:

After 6 months of first hypospadias surgery, the child was taken up for second stage urethroplasty. We checked chordee again- the penis was completely straight. The prepucial flaps which were done in first stage had healed very well. The flaps were wide and supple. 15mm wide incision was marked on the flaps and, local anaesthesia was infiltrated at the marked site and incisions were deepened till corpora and hemostasis checked. Urethroplasty was done over 7Fr Infant feeding tube in two layers with 6-0 PDS absorbable sutures. Glans wings were raised, Glansplasty was done, and a new meatus was made on the glans. The dressing in the post operative period was changed on post operative day 7 and catheter was removed on post operative day 10. Child was passing urine through the new opening in good stream.

Picture 7: Prepucial flaps 6 months after stage 1 were healed very well. Flaps were wide and supple.

Picture 8: Artificial erection test done – completely straight penis noted

Picture 9: Urethroplasty done over 7Fr Infant feeding tube and dartos flap raised on both sides

Picture 10: Glans wings raised, distal urethroplasty done and Dartos flap sutured over the urethroplasty.

Pic 11: Glansplasty and skin closure done, completing Stage 2 urethroplasty

Pic 12: Post catheter removal, passing urine in single straight stream with no complications.

Two stage repair in hypospadias with severe chordee

Staged repair in hypospadias is a preferred approach in cases of severe hypospadias when the urethral opening is significantly displaced and there is significant chordee. Two stage repair involves two separate surgeries to correct the hypospadias, the first stage being correction of the bend of the penis and rearranging the foreskin on the underside of the penis. The second stage is usually performed 6-12 months after stage 1 hypospadias repair.

Two stage repairs are often considered to offer superior functional and cosmetic results in severe hypospadias compared to attempting a single stage complex repair. They allow for a
more controlled approach to address significant curvature and create a neourethra with potentially better tissue quality from the prepucial flaps. Whether your child needs a single stage repair or a staged approach is best decided by the expert hypospadias surgeon during the initial steps of surgery and is primarily dictated by the degree of curvature.

About Hypospadias foundation

Hypospadias foundation is an organization dedicated for children and adults with hypospadias and is rated as the best hospital for hypospadias repair in India and the World. Hypospadias foundation offers best results for surgical repair for primary and failed(redo) hypospadias. We at hypospadias foundation believe in providing personalized care and psychosocial support to families of children and adults with hypospadias. Dr A K Singal is a well renowned hypospadias surgeon and regarded as the best hypospadias surgeon in India and in the world. His vision for hypospadias has helped him achieve excellent outcomes in adults and children with hypospadias. He has dedicated his life in treating children and adults with hypospadias with his innovative surgical techniques. Dr Ashwitha Shenoy is an expert pediatric surgeon with special interest in pediatric urology and hypospadias. She holds a particular interest in hypospadias and along with Dr Singal performs advanced surgical techniques for both primary and complex hypospadias cases in children and adults.

July 07 2025

Penoscrotal transposition correction and hypospadias repair in a 2- year-old boy

2-year male child presented to hypospadias foundation with abnormal position of the penis in relation to the scrotum (penoscrotal transposition). On examination, there was ventral chordee (abnormal curvature of the penis), complete prepuce and complete penoscrotal transposition. Meatus was glanular in position. He was planned for single stage repair of glanular hypospadias, ventral chordee and penoscrotal transposition.

The surgery was started by completely degloving of the penis and assessment of chordee. No chordee was noted after complete degloving. Since the meatus was proximal glanular he underwent distal urethroplasty and glansplasty. Marking was done for penoscrotal transposition correction. Inverted V-shaped incisions were given at the base of both scrotal halves with the midline joining on the ventral aspect at the base of the penis. Both the scrotal halves were dissected deep till the subcutaneous level and rotated to the ventral side and fixed at the base of the penis.

Dressing and catheter were removed on post-operative day 7. The child passed urine well following catheter removal.

Fig 1: Hooded prepuce with complete penoscrotal transposition

Fig 2: Proximal glanular meatus. Marking done on the ventral and dorsal side.

Fig 3: Chordee assessed by artificial erection test and no chordee noted.

Fig 4: Inverted V shaped incision for penoscrotal transposition correction

Fig 5: Scrotal flaps dissected and sutured on the ventral side

Fig 6: Post operative outcome 2 months after surgery

Penoscrotal transposition correction and hypospadias repair in a 2- year-old boy

Penoscrotal transposition (PST) is a rare congenital condition where there is abnormal arrangement of the penis and the scrotum.

There are two main types:
1. Incomplete PST: The penis is located in the middle of the scrotum
2. Complete PST: The penis is positioned below the scrotum, in the perineum.

Penoscrotal transposition is often associated with other congenital abnormalities, including hypospadias, undescended testis, cardiac anomalies, craniofacial deformities, gastrointestinal disorders or intellectual disability.

Minor penoscrotal transposition does not need repair. Complete transposition can be repaired by surgery. The goal of the surgery is to restore the normal anatomical position of the penis and scrotum.

When penoscrotal transposition and hypospadias occur together, it can make the condition more complex and challenging to treat. In minor hypospadias, penoscrotal transposition can be corrected along with hypospadias repair.

In severe hypospadias, we perform the hypospadias repair first and the transposition correction later only if necessary. Penoscrotal transposition correction is done purely for cosmetic reasons. If your child has penoscrotal transposition, then do consult an expert pediatric urologist and take an informed decision before proceeding with the surgery.

About Hypospadias Foundation:

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 and its associated conditions. 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 is an expert and top hypospadias surgeon in India. He is a gifted surgeon and his expertise in this area has helped us achieve excellent outcomes in primary and failed hypospadias in children as well as adults.

Dr Ashwitha Shenoy is an expert pediatric surgeon with special interest in pediatric urology and hypospadias. She holds a particular interest in hypospadias and along with Dr Singal performs advanced surgical techniques for both primary and complex hypospadias cases in children and adults.

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