Staged hypospadias repair for complex scrotal hypospadias in a 10-year-old boy

A 10-year male presented to Hypospadias Foundation Clinic with complaints of passing urine from the scrotal region. As a result, he had to sit and pass urine even at this age. He also had a congenital heart defect (Atrial septal defect) for which he had undergone surgery at 4 years of age and had recovered well. Since he had associated cardiac defect, parents decided to get the hypospadias surgery later hence the late presentation of hypospadias.

On examination in the OPD, the meatus was in the scrotal region and there was downward curvature of the penis. Also, the right testis was undescended, not palpable in the scrotum but was palpable in the inguinal region. The size of the penis was measured and was found to be normal for age i.e Stretched penile length- 33mm and Glans diameter was 16mm. Karyotyping was done in view of hypospadias associated with undescended testis and was noted to be normal male karyotype (46XY). Parents were counselled for two stage hypospadias surgery in view of scrotal hypospadias with significant chordee.

Surgery was started by taking stay stitch on the glans with 4-0 prolene and complete degloving was done. Deep degloving was done which is till the scrotal pad of fat on the ventral side and till the suspensory ligament on the dorsal side. After complete degloving, artificial erection test was done to assess the degree of chordee. Chordee was more than 90 degrees. Spongiosum was mobilized on either side and urethral plate was divided. Proximal urethra was mobilized till the scrotal region. Dysplastic tissues on the ventral side were removed and chordee reassessed. Persistent chordee of more than 60 degree was noted. Ventral corporotomies were done by placing 3 horizontal incisions on the ventral side with the middle incision at the site of maximum curvature. Even after corporotomies, the chordee was significant. Hence, we planned to proceed with ventral lengthening procedure called as dermal graft. Deep corporotomy was given at the site of maximum curvature which is the site of middle corporotomy. This was a transverse incision made from 3’o clock to 9’o clock position preserving the erectile tissue. Dermal graft was harvested from the left inguinal region. Elliptical incision was given in the left inguinal region at the lowest skin crease. Defatting and de-epithelization of the graft was done. Dermal graft was then sutured at the site of tunical defect with 6-0 PDS interrupted sutures. Chordee was assessed after dermal graft placement and no chordee noted.

Once the chordee was completely corrected, the proximal urethra was sutured at the proximal penile region. Glans wings were raised. Byars flaps were created by dividing the dorsal prepuce in the midline and rotating it to the underside of the penis and sutured from the glans till around the meatus at the penoscrotal region. Right undescended testis was brought to normal scrotal location completing the orchidopexy at the end of the surgery hence completing both orchidopexy and stage 1 hypospadias repair (chordee correction and byars flaps).

Second stage hypospadias repair:

After 6 months of stage 1 chordee correction, the child underwent second stage urethroplasty. Artificial erection test was done at the start of the procedure to assess the presence of any residual chordee. No residual chordee was seen. The prepucial flaps which were done in stage 1 had healed well. The flaps were wide and supple with good blood supply. 15mm wide marking of the flaps were done, local anaesthesia infiltrated at the marked site and incision given. Incisions were deepened till the corpora. Excess skin on either side was trimmed. Urethroplasty was done over 7Fr catheter in 2 layers with 5-0 vicryl. Glans wings were raised. Dartos flap was raised from both sides and sutured over the urethroplasty. Glansplasty was done. A new meatus was created on the glans. Post operative period, dressing was changed on post operative day 7. Catheter was removed on post operative day 10. He was passing urine in single straight stream without pain after catheter removal. Parents were very happy with the outcome and boy was overjoyed to stand and pass urine in a single straight stream.

30-year-old male presented to the hypospadias clinic with complaints of passing urine from the distal penile region. He had not undergone any surgery in childhood since his parents were not aware about their child’s hypospadias condition. On examination in the OPD, the meatus was narrow and was in the distal penile region. He also had significant chordee on erection. He was counselled for single or two stage repair depending on the estimation of degree of chordee in the operation theatre.

Stage 1 Repair- Chordee correction and Oral Mucosa graft

The hypospadias repair surgery was started by complete degloving. Artificial erection test after degloving showed more than 45-degree ventral chordee. Since the chordee was significant with the urethra appearing short and taut, the urethra was divided, and proximal urethra was mobilized. Artificial erection test after urethral plate division showed less than 30-degree chordee, hence we decided to correct it by dorsal 16 dot plication procedure.

Buck’s fascia along with neurovascular bundle was raised on the dorsal side starting laterally on either side and upto the midline. Artificial erection test was done, and exact site of maximum curvature was marked on the dorsal side. 16 dots (8 dots on either side) were marked- 4 dots proximal and 4 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 completely corrected by these equally spaced plication sutures. Buck’s fascia was closed on either side with 6-0 PDS. Proximal urethral stump was fixed at the proximal penile region. Distal tunical bed was prepared for placement of oral mucosa graft. Glans wings were widely raised.

A long 10cm Oral mucosa graft was harvested from inside of the right cheek and lower lip. Graft was defatted and quilted in the urethral bed with 5-0 vicryl. Pressure dressing was done, and the catheter was fixed to the glans stitch. Dressing and catheter were removed after 7 days.

Graft uptake in this case was 100% with no graft loss. After 21 days, local steroid massages were started and continued till 5 months.

Stage 2 Oral Mucosa Graft Urethroplasty

Graft was soft and supple at 6 months after graft placement. Surrounding skin was also heathy and soft. Urethroplasty was started by marking the edges of the graft. Local anaesthesia was infiltrated at the marked site. U-shaped incision was given at the edges of the graft and was deepened till the corpora. Urethroplasty was done over 14Fr silicone catheter with 5-0 vicryl in 2 layers. Local dartos flap was used for second layer coverage. Skin was closed in 2 layers and dressing was done. Suprapubic cystostomy was done with 14Fr malecot’s catheter. Dressing was
changed on post-surgery day 4 and every 4 th day thereafter. During every dressing change, betadine wash was given, and redressing was done. Per urethral catheter was removed on post operative day 14. Suprapubic catheter was removed on post operative day 21. Patient passed urine in good stream without pain or leak after catheter removal. At 6 months follow up after surgery, the cosmetic result was good, and the patient was passing urine from the glanular meatus in good stream.

Distal penile hypospadias repair surgery in an adult

Hypospadias is a congenital condition which is present since birth. When not operated in childhood, adults visit our Hypospadias Foundation Clinic for surgical repair in adulthood. The above mentioned case is of a 30 year old male who presented to us with distal penile hypospadias with severe chordee. He was counselled that the decision of single or two stage will be taken during the surgery after assessment of the degree of chordee.

Artificial erection after degloving showed significant chordee and we had to proceed with staged repair. In first stage, the chordee was completely corrected by urethral plate division and dorsal 16 dot plication. We avoid corporotomies in adults because then oral mucosa graft uptake is poor at the sites of deep corporotomy. In adults, the length of oral mucosa graft required is usually long andd hence mostly it needs to be harvested from the cheek and lip. Steroid massages are started on the graft 3 weeks after graft placement.

Second stage is planned 6-8 months after stage 1. Suprapubic cystostomy is a must in all post pubertal and adults undergoing urethroplasty. Post surgery care is extremely important in adults after hypospadias repair. At our centre, we inspect the operated site once every 4 days to make sure that there is no surgical site infection because wound infection after stage 2 can cause dehiscence of the the entire urethroplasty. We remove per urethral catheter first which is around 14 days followed by SPC clamping and removal at 21 days provided there is no dehiscence.

After having done hundreds of adult hypospadias surgeries, we can clearly see differences in adult hypospadias repairs compared to hypospadias repair in a child. Whether it is the size of penis, overall anatomy of tissues, pre-surgery preparation, intra operative sutures or post-op care- everything is very different. Over the years, we have developed various steps which should be done to decrease risk of hypospadias surgery complications in adults. This has led to improved results with more than 95% success rate after hypospadias repair with very few adults requiring another surgery.

At Hypospadias Foundation, a dedicated team of surgeons Dr A.K. Singal and Dr Ashwitha Shenoy take care of adult hypospadias. Dr A.K. Singal is a reputed and top hypospadias surgeon who has been doing hypospadias repair surgeries since 2006 and is rated amongst the best in India and the world for his excellent results. Dr Ashwitha Shenoy is a hypospadias surgeon with experience in managing hypospadias. Both work very closely giving best outcomes to adults with hypospadias. Given their teamwork and dedication to success rates in hypospadias, children and adults come from all over India and more than 20 countries to seek hypospadias treatment under their care.

25-year-old adult presented to the Hypospadias Foundation OPD with complaints of severe ventral curvature of the penis. There were no urinary complaints. He also that the curvature has worsened over time. There were no urinary complaints.. On examination, there was severe ventral curvature (downward bending) of the penis- the curvature was almost 90 degrees. 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 chordee repair surgery.

The plan was to deglove the penis, examine everything once again in detail including degree of curvature, urethral calibre and then decide for a single stage or a staged chordee correction repair.

Surgery was started by taking a stay stitch on the glans with 4-0 prolene. Marking of the degloving 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 plicationprocedure 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. The sutures were first held tight without tying them up and chordee was reassessed and there was no chordee. Once we were sure that the chordee is fully corrected, we tied off the sutures and checked chordee again- 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 anddressing was done. Catheter was removed after 7 days. At follow up at 6 months after surgery, there was no chordee and the erection was straight.

Severe ventral chordee in adults: Diagnosis and management

Chordee is characterised by the curvature of the penis, which is noticeable only during penile erection. While chordee can occur in adulthood due to Peyronie’s disease, most of the cases of chordee are present from birth (congenital). Chordee can be missed in childhood, especially if there is no hypospadias. In such cases, men present with challenges in adulthood,d such as pain during erection, difficulty in sexual intercourse and some men can also have psychological implications impacting self-esteem.

In chordee, there is a noticeable bend in the penis during an erection, which can be downward, upward or sideways. The most common chordee type is ventral chordee, where the penis bends downwards, as in the present case. Surgical correction is the only effective method of chordee correction in adults. The goal of the chordee correction surgery is to straighten the penis and restore normal function. Chordee correction can be done by dorsal plication or a ventral lengthening procedure. The ventral lengthening procedure is done if there is a 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 procedur,e 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 a parallel fashion to create plications in the tunica albuginea. Neurovascular bundles are carefully raised and saved from any injury 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 specializes 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 and chordee. We provide support and information for children, adults and their families affected by 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. 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. Both Dr Singal and Dr Shenoy work together to give best results for hypospadias surgery in India for both children and adults.

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.

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.

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.

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.

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.

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.

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.

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.

5-year-old boy with distal penile hypospadias, had undergone two surgeries somewhere else and came to Hypospadias Foundationnted with complaints of difficulty in passing urine from the meatus and urine leak from the distal penile region. On clinical examination, there was residual chordee, fistula in the distal penile region and penile torsion to the right.

At our centre, he was planned for cystoscopy, chordee assessment and single or two stage repair based on the cystoscopy findings. On cystoscopy, we found stricture of length 1.5cm in the distal urethra (beyond the site of fistula) and normal proximal urethra.

As a first step, the penis was degloved. Fibrotic bands were released during degloving. Chordee was assessed by artificial erection test and no chordee was noted. The dorsal penile skin (residual prepuce) looked healthy with preserved vascularity. Hence, we planned to go ahead with the urethroplasty in single stage using an onlay flap from this residual prepuce.

15x8mm flap along with the good vascular dartos tissue was raised from the dorsal side. Flap was rotated around the side of the penis and brought to the underside of the penis for urethroplasty. Urethroplasty was done using 6-0 PDS over a 7Fr infant feeding tube. Dartos tissue was fixed on either side to cover the urethroplasty. Glans wings were raised widely and glansplasty done using 6-0 PDS. Excess skin was trimmed on the right lateral side and repositioned to correct the penile torsion and to achieve a better cosmetic result.

Single stage hypospadias repair in a child using onlay flap from residual prepuce after previous failed surgeries

Hypospadias is a birth defect in boys where the urinary opening is on the underside of the penis. One of the popular techniques used for hypospadias repair is a Prepucial Onlay Flap urethroplasty. In this surgery, a well vascularized flap is raised from the dorsal prepuce and used to reconstruct the urethra.

This technique can also be used in failed hypospadias in the presence of residual prepuce and with no or minor chordee. The success rate of onlay flap in a failed hypospadias varies depending on several factors including the severity of the hypospadias, the surgeon’s experience, vascularity of the penile skin etc. During the surgery, flaps must be carefully raised preserving the vascularity otherwise there is risk of flap necrosis and complete dehiscence. Post surgery dressing should not be tight because it can cause compression of the flap and compromise the vascularity. This repair has good outcomes when performed by an experienced hypospadias surgeon.

If your child has undergone prior hypospadias repairs and developed a complication, then do consult an expert hypospadias surgeon for your child. Discuss the best options for your child and take an informed decision from the best in the field of hypospadias.

About Hypospadias Foundation

Hypospadias Foundation is a centre specialized for treatment of children with hypospadias. Our expertise in hypospadias makes us one of the best centres for hypospadias repair in the world. We treat children from more than 25 countries in the world and from all over India. Our dedication in this field has helped us achieve excellent outcomes. Hypospadias foundation is located at MITR Hospital in Kharghar, Navi Mumbai in the state of Maharashtra.

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 hypospadias surgeon with special interest in hypospadias and pediatric urology. Both Dr Singal and Dr Shenoy work together to give best results for hypospadias surgery in India for both children and adults.