Chordee is a condition where the penis is curved downward. Most of the times it is associated with hypospadias but can occur without hypospadias. Chordee correction is very crucial step during hypospadias repair. Without chordee correction, urethroplasty should not be attempted because there will be a stress of the urethral passage and there is high risk of complications after surgery.

Chordee surgery is usually successful in correcting the curvature of the penis completely. However, there is a small chance that chordee can come back after surgery. This is called recurrent chordee.

Risk factors for recurrent chordee:

• Incomplete correction of chordee: When the chordee is severe, it must be corrected completely during chordee correction surgery. If there is any residual chordee after chordee correction surgery, it will only worsen in the future.
• Fibrosis during healing: After chordee correction, fibrosis can occur on the underside of the penis during healing process. Sometimes the fibrosis can improve with steroid massage but if it persists then recurrent chordee correction may be required. This fibrosis can be at the level of skin, tissue under skin or even urethra.
• Due to flaps: Recently we have seen some cases where tunica vaginalis flaps were used for second layer cover during hypospadias surgery at other centres. Somehow the flaps didn’t heal well and they caused chordee to come back. Similar outcomes we have seen when a very tight urethra was made from prepucial flaps or koyanagi repair in first surgery.

Symptoms of recurrent chordee:

The common symptoms which children present with are downward bending of the penis, urine which goes backward and may have occasional pain during erections.

Adults with recurrent chordee may have pain during erection, inability to perform sexual intercourse, painful sexual intercourse and infertility

Treatment for recurrent chordee:

If you think you may have recurrent chordee or your child has recurrent chordee, it is important that you see a doctor right away. You need to visit a hypospadias surgeon or a pediatric urologist who has expertise in the field of hypospadias and chordee correction.

Chordee correction can be done by various methods. First and foremost, the cause for recurrent chordee has to be identified and then appropriate method is used to correct chordee. Chordee correction method differs for children and adults.

1. If a child presents with residual chordee due to incomplete chordee correction in the past, then the following methods of chordee correction are used: Complete degloving is done and chordee is assessed, if chordee persists even after degloving then the following methods are adopted.  If the chordee is due to short urethra due to flaps or tunica vaginalis flaps, we divide them at this stage.

Pre degloving and post degloving chordee assessment

(a) Dorsal tunica Albugenia Plication (TAP): If the chordee is less than 30 degree then it can be easily corrected by placing a non-absorbable suture at the site of maximum curvature on the dorsal side(upper side) of the penis. This will correct the chordee completely.

Post Degloving showed less than 30-degree chordee. 12’o clock dorsal tunica albuginea plication done. Chordee completely corrected by this plication.

No chordee noted after 12’o clock dorsal tunica albuginea plication

(b) Urethral plate division and Proximal urethral mobilization: If the chordee is more than 30 degrees then one of the reasons for persistent chordee is short urethra, in these cases we will have to divide the urethral plate ventrally and mobilize the proximal urethra. This will effectively correct chordee if it is due to congenital short urethra.

Urethral plate division and proximal urethral mobilization

(c)If chordee persists inspite of urethral plate division then urethral mobilization, ventral corporotomies are done. This will correct the chordee if the cause for chordee is due to disproportionate corporal bodies.

Three ventral corporotomies

(d) If none of the above measures can correct chordee then we perform a ventral lengthening procedure called as the dermal graft. Deep incision is given in the tunica on the ventral side at the site of maximum curvature and dermal graft is placed at the site. This method is adopted in cases of severe chordee.

Dermal graft

The chordee is corrected completely after the above steps of chordee correction.

2. If the child presents with severe chordee inspite of complete chordee correction in the past, then it is most likely due to ventral fibrosis. In these cases, along with some or all the above methods, removal of fibrotic tissues from the underside of the penis is important to correct the chordee.

Adults with recurrent chordee after previous surgery

In most of the adults at first we assess the fibrosis and degloving is done. If the chordee is still there, then we divide the urethral plate and mobilise it. Post this, if the chordee still persists, we can correct chordee completely by a method called as “16 dot plication”. In this method, 4 sutures are placed on either side of maximum curvature on the dorsal side, which will correct the chordee uniformly in an adult penis.

In most of the cases of recurrent chordee in addition to chordee correction, urethroplasty will also be required. In redo cases, chordee correction and urethroplasty will most likely be done in two to three stages and oral mucosa graft will be used in more than 95% of such cases. Only in few exceptional we may be able to repair everything in single stage.

About Hypospadias Foundation India:

Hypospadias Foundation in Navi Mumbai, India is dedicated to offering care and cure for chordee and hypospadias in children and adults. Set up in 2008, more than 3000 children and adults have benefitted from care and achieved best in class results for chordee and hypospadias. Dr A.K.Singal and Dr Ashwitha Shenoy, hypospadias expert surgeons at Hypospadias foundation have dedicated their lives to the art and science of hypospadias repair.

If you feel your child or you are suffering from recurrent chordee even after previous chordee correction, then do get it checked by an expert pediatric urologist or a hypospadias surgeon. Chordee correction surgery has good result when done in childhood than in adulthood. Do not hesitate to write to us or contact us

Contacting the Hypospadias Foundation:

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

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

Keywords: recurrent chordee, residual chordee, chordee repair, chordee repair surgery, chordee correction surgery, bent penis repair, best hospital for hypospadias in india, best hypospadias surgeon, hypospadias repair in india, adult chordee repair, dermal graft repair, 16 dot plication for chordee

For some men with hypospadias, a congenital condition where the urethral opening lies somewhere on the underside of the penis, questions about fertility can loom large. While hypospadias itself doesn’t directly impact sperm production, its associated complications can sometimes pose challenges. Hypospadias cause male infertility in certain cases due to these complications. But remember, this doesn’t mean that all men with hypospadias will necessarily be infertile. Let’s delve into the link between hypospadias and fertility, exploring potential concerns, available solutions, and fostering hope for fatherhood.

Understanding Hypospadias:

During fetal development, normally the urethra forms by folding of tissues from scrotum to the base of the penis to the tip of the penis. The failure of this urethral closure leads to hypospadias. The severity of hypospadias varies, with the opening appearing anywhere from the scrotum (scrotal hypospadias) to the base of the penis (penoscrotal hypospadias) to near the tip of the penis (distal hypospadias). Besides the misplaced opening, most men with hypospadias also have a downward bending of the penis during erection – called chordee. Hypospadias can cause male infertility as 5% of cases may also have an associated undescended or absent testis, which can lead to lower sperm production. Such men need to be investigated for a disorder of sex development (DSD) or intersex.

Hypospadias and Fertility: the Possible Connections:

In isolated hypospadias with both normal testes, the sperm production usually remains unaffected, yet certain hypospadias-related factors can influence fertility:
 Urethral location: In severe unrepaired hypospadias cases such as scrotal or perineal or penoscrotal hypospadias, ejaculation might not be able to reach the vaginal introitus, hindering fertilization.
 Penile curvature: Significant curvature can make intercourse physically difficult. Sometimes erection can also be painful when there is significant chordee
 Meatal stenosis: abnormal hypospadias opening may be very small leading to urinary and sperm flow obstruction.
 Prostatic utricular diverticulum: Some men with severe hypospadias may also have a large sac near their prostate gland where sperm tubes (vas deferens) open. In such cases sperms may not flow out easily for fertilisation.
 Post hypospadias surgery issues: At Hypospadias foundation, we see lot of men who have had repairs done earlier and have poor fertility though they have a normal sperm production. The common reasons for this are complications of hypospadias surgery such as: residual curvature or chordee, stricture in new passage, diverticulum or baggy new urethra or fistulae in the urethra.

 Psychological considerations: Emotional concerns about body image or sexual function can sometimes affect intimacy and overall fertility.

Hypospadias Treatment Options: Paving the Way for having children
Fortunately, advancements in hypospadias surgery and infertility treatment offer effective solutions for addressing hypospadias-related fertility concerns:
 Hypospadias repair surgery: This procedure reconstructs the urethra and corrects penile curvature, often restoring normal ejaculation and improving sexual function. If there are complications from previous hypospadias surgeries such as stricture, residual chordee, fistula or a diverticulum- these can be repaired by an expert hypospadias surgeon leading to cure for infertility.
 Assisted reproductive technologies (ART): In cases where natural conception proves challenging, sperm retrieval techniques like testicular biopsy or micro epididymal sperm aspiration (MESA) can be combined with IUI, IVF, or ICSI to achieve pregnancy.

Maintaining Hope: Fatherhood is Within Reach for people with Hypospadias:
Do consult an expert and best hypospadias surgeon first. The hypospadias surgeon will check and confirm that the hypospadias repair is proper and there is no structural issue in repair. If there is some residual issue in hypospadias surgery, then that needs to be corrected first. If the infertility persists, and you suspect hypospadias cause male infertility, then you must visit an andrologist for assisted reproductive techniques.

It’s crucial to remember:
 The majority of men with hypospadias have normal fertility.
 Early surgical intervention significantly improves the chances of successful fatherhood.
 Advanced treatments like ART offer alternative paths to parenthood. Open communication with your hypospadias doctor is key to understanding your unique
situation and exploring suitable fertility options. Remember, hypospadias does not define your potential as a father. With proper support and available treatments, you can navigate this journey and realize your dreams of having babies and building a family. At Hypospadias foundation, we treat hundreds of children and adults with hypospadias every year. Since 2008, Dr A.K.Singal, rated as the best pediatric urologist and hypospadias surgeon in India and the world, has devoted his life to helping people with hypospadias get best results and normal life. Along with Dr Ashwitha Shenoy, pediatric surgeon and hypospadias surgeon and a partner at Hypospadias foundation, the team at Hypospadias foundation, has deep expertise in diagnosing and treating complex hypospadias.

References:
 American Urological
Association: https://university.auanet.org/core/pediatric/hypospadias/index.cfm
 National Institutes of Health: https://www.ncbi.nlm.nih.gov/books/NBK482122/
 Mayo Clinic: https://www.mayoclinic.org/diseases-
conditions/hypospadias/diagnosis-treatment/drc-20355153

If you wish to have a teleconsult or a second opinion from Dr Singal/ Dr Shenoy, please write to us hypospadiasfoundationindia@gmail.com or fill up this contact form: https://www.hypospadiasfoundation.com/contact/

Surgery Steps:

Marking of the degloving incision, a crucial step in surgery for distal hypospadias and penile torsion, commenced the procedure. Local anesthesia was meticulously infiltrated at the marked incision site to ensure patient comfort. The surgical process proceeded with complete degloving and assessment of chordee, revealing a 30-degree chordee. Chordee correction was expertly performed through Tunica albuginea plication at 12 o’clock on the dorsal side, resulting in the successful elimination of chordee. Urethroplasty commenced with precise incision of the urethral plate in the midline, followed by meticulous suturing over a 7Fr Infant feeding tube with 6-0 PDS continuous sutures. Additional measures included the harvesting of a Dartos flap for extra coverage over the urethroplasty, secured with 6-0 PDS sutures. Penoscrotal web correction was also addressed, with excess skin excised and meticulously sutured using 5-0 vicryl rapide. To address penile torsion, skin flaps were rotated and adjusted, ensuring optimal alignment, and meticulously sutured all around using 5-0 vicryl rapide. Postoperative care included a 7-day period with dressing and catheter in situ, followed by their removal to facilitate the patient’s recovery.

Results

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

About Hypospadias repair and penile torsion

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

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

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

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

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

About Hypospadias Foundation

Hypospadias foundation is a centre which provides personalized and best quality care for children and adults with hypospadias. It is one of the best hospital centres in India and world for surgical treatment for hypospadias in adults and children.  Our dedication in the field of hypospadias has helped us achieve excellent outcomes in these patients. We treat children and adults not only from various parts of India but also from more than 25 countries all over the world. Hypospadias foundation is located at MITR hospital in Kharghar, Navi-Mumbai, Maharashtra, India. Every year more than 200 surgeries for hypospadias are performed at MITR hospital and Hypospadias Foundation

Contact us:

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

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

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

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

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

Dr Singal with Dr Long & Dr Zaontz

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

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

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

Hypospadias is a common urological anomaly and fortunately most of the hypospadias are distal or midpenile in variety with good results in one stage surgery. Scrotal hypospadias are the most severe forms of hypospadias where the opening in far behind in scrotum, in between the testicles. 6 months back we treated a child with hypospadias who travelled with his family all the way from Australia for a hypospadias repair surgery. But the story actually started as soon as the baby was born. The family had contacted us for an email and telephonic consultation and we were there with them from the neonatal age till the surgery and the care continues electronically even now.

Fortunately, with meticulous pre-surgery planning and good support we could get a good result of the surgery in one stage itself. The child is doing very well now and doesn’t look like that he will need any further hypospadias surgery. The family was overjoyed and they have sent us an email now (6 months after surgery) and we were all very happy to read the email. It made our day and also made the whole purpose of starting Hypospadias Foundation worthwhile.

We have taken the liberty of using most of the email in an unedited format here after seeking due permission from the family.

Hi Dr. Arbinder Singal,

How are you?

Please find below what we truly felt. Also as discussed, we would not prefer either our or or son’s name to be reflected in the recommendation, however please feel free to provide my details to parents who are in a similar situation and need help just like we did when our son was diagnosed with severe hypospadias.

 First News

 It all started on 2^nd December when my son was born in Sydney (Australia), it was the happiest moment of my life but I didn’t know that it will last only for the next 24 hours. 

The next morning, as a usual process in Australian Hospitals, Specialists came to check my son and called me. The specialist checked my son and without any emotions or sympathy or even empathy told me that my son is suffering from Hypospadias and that too a severe one and it will take at least 2-3 operations period. My ears were striving hard to hear that after those operations it will be completely cured and everything will be fine but the doctor told me that the Hypospadias is severe and there is no guarantee and gave me an information booklet with scary after operation images. As far as I remember I asked him thrice may be more that whether my son would be alright after those operations? yearning for an answer that “everything will be alright” may be a pat on my shoulder to give me some strength or courage to deal with the situation but he left without saying even a single positive word. 

I could barely walk after that conversation, everything around was meaningless and sad. My wife was still in the hospital recovering from the caesarean operation, I chose not to tell anyone in my family and let them be happy.  I came home that night as you are not allowed to stay in the hospital in Australia. I was not able to sleep that night and the next morning while I was still at home, all my emotions came out, I couldn’t stop the tears and my family came to know about it and tried to give suggestions but that doctor had filled my whole system with so much negativity that I believed that there is no solution and my son will never be cured. After venting out my emotions, I started researching about Hypospadias specialists in the world and I found Dr V.R.Jayanthi and called his clinic in U.S.A but he was not available. I did some more research and found Hypospadias foundation in Navi Mumbai, India. Honestly I didn’t care to read the content on the site  and went directly to the contact us page as I was so desperate to talk to a specialist and got through Dr. A.K. Singal’s clinic and fortunately they helped me to set up an telephonic appointment with him. 

Half an hour Conversation changed everything!

Carrying a huge backlog of negativity, I called up Dr. Arbinder Singal. The conversation started with a lot of questions and Dr. Arbinder Singal listened to all my questions and concerns patiently and irrespective how silly the questions were, he answered to every question in detail. Honestly that conversation changed my life and in particularly one sentence from him – “THERE IS NO HYPOSPADIAS WHICH CANNOT BE CURED”. He guided me to contact a pediatric endocrinologist right away and explained in detail on how to proceed with the next steps. I recorded that conversation and told my wife about the news because now I had the solution – Dr. Arbinder Singal!

A Close shave

I am really thankful to Dr. Arbinder Singal for recommending a pediatric endocrinologist at that point. I want to again emphasize here that everyone apart from Dr. Arbinder Singal missed an important step in the journey – Meeting a Pediatric Endocrinologist.  

As per the paediatric endocrinologist – Dr. Andrew Biggin (he is still my son’s paediatrician and has agreed to mention his name) there were some injections which needed to be given to my son before a certain age which we would have definitely missed as no other Doctor asked us to meet a paediatric endocrinologist.  We communicated a lot with Dr. Arbinder Singal updating him about the progress and again asking questions to which he patiently responded every time. He also helped us to get in touch with the other parents whose children had undergone hypospadias repair surgery under his care which helped a lot as they explained us how they went through the treatment and journey. We are really thankful to those parents as well as every time we had an emotional breakdown or we felt nervous they acted as a big emotional support and had long conversations calming us down. Finally Dr. Arbinder Singal helped us decide a date and hospital for hypospadias operation.

The Surgery..

We travelled to India for surgery and we arranged a villa near Fortis Hospital in Vashi, Navi Mumbai and went to meet Dr. Arbinder Singal for the first time in Mumbai. After our meeting the comfort level and confidence increased multi-fold, he was very nice to speak with and inculcated the same confidence in us. He checked my son and said he will try to do it in one operation itself. We had already booked a room in Fortis and admitted my son for the surgery. We met him again before the hypospadias operation, we were nervous but we were calm as we knew that our son was in safe hands. All the hospital staff was very helpful on the operation day and Dr. Arbinder Singal gave us the good news that the operation is successful and my son would not need another surgery.

Highly Highly Recommended!

I would highly recommend Dr. Arbinder Singal as he is an hypospadias expert and good human being. He is reachable and understands the emotions & nervousness which the parents go through. All the more the issue which all the doctors in Australia could solve only by doing multiple hypospadias surgeries, he did that in one go with a single stage hypospadias repair.

I and my family are and would be really thankful to him for forever.

Thanks Dr. Arbinder Singal & Hypospadias Foundation!!

Regards,

A happy kid and his family

Sydney, Australia

About Hypospadias Foundation and Dr A.K.Singal

Hypospadias Foundation is an organisation dedicated to care & cure for patients children and adults suffering from Hypospadias and DSD (disorders of sex development). It is located within a boutique Urology centre – MITR Hospital in Kharghar, Navi Mumbai, India (www.mitrhospital.com ). Hypospadias Foundation was started in 2009 by Dr A.K.Singal and Dr Manish Dubey and till date more than 800 children and adults have been treated at the Foundation from all over India and more than 20 countries (june 2015). The foundation keeps on growing with blessings from families and support from society.

Hypospadias is one of the most common urological anomalies in boys. While 80% of all hypospadias are mild and of distal or midpenile, 20% are proximal hypospadias. Severe varieties like scrotal hypospadias form only 5% of total burden of hypospadias. Severe hypospadias such as scrotal hypospadias often have associated chordee (bent penis) and this may be very severe too posing a challenge for the hypospadias surgeon. We have realized in last few years that making the penis straight (chordee correction) is THE MOST IMPORTANT step of hypospadias repair procedure. While most of the severe scrotal hypospadias are also repaired in a single stage (almost 90% are suitable for a single stage urethroplasty), in 10% of the children the anomaly is so severe especially due to severe chordee that two stage repair may be better for an optimal long term outcome.

Master R.P. was born with scrotal hypospadias, severe chordee in Patna, Bihar and was advised to undergo surgery after 1 year of age. The parents went to multiple doctors in Patna, Delhi and finally came to consult Dr A.K.Singal, renowned Hypospadias surgeon at MITR Hospital, Navi Mumbai. On examination, the child had a severe scrotal hypospadias, severe chordee (almost 90 degrees) and abnormally fused skin of scrotum to the penis. This almost looked like a trapped hypospadias penis due to skin shortage. Dr Singal discussed in detail with parents that such a severe hypospadias may require hypospadias treatment in stages. Due to the severity it may be impossible to correct all the defects in one surgery. Also the penis length may have got shortened and cosmetic result would also been suboptimal.

Finally, R.P. was taken under anesthesia and hypospadias repair surgery was started. As a first step the penis was degloved. Urethral plate was divided and the fibrous bands causing chordee on the underside of penis were divided deeply till the scrotum. The penis was almost straight after this maneuver with just 30 degree bend which was further corrected by a placing a placating stitch on the top side of penis (tunica albuginea plication or TAP). Artificial erection test confirmed the complete correction of chordee. Since the chordee was severe and the urethral plate was also divided, single stage surgery would have carried very high failure rates. Hence, a staged urethroplasty was planned. The skin on the top of the penis was divided in midline and brought to the underside of penis. A part of the skin was advanced into the head of penis (glans) so that the new urethra in next stage would be constructed till the tip of penis. This is called Thiersch Byar’s urethroplasty stage-1. There was a compression dressing done which was removed after 7 days and the family travelled back to Patna after a total of 14 days after first hypospadias surgery.

Hypospadias is the most common urological anomaly (birth defect) seen in newborn babies worldwide. It is mostly diagnosed soon after the baby is born when the opening of for urine is seen to be on underside of penis, the foreskin (prepuce) is incomplete on the underside and there may be a bend in the penis (chordee). Very rarely, if the hypospadias is very mild, it can be missed on neonatal examination by even a pediatrician.

Lot of countries and religions practice and advocate newborn circumcision in all male babies but whenever hypospadias is diagnosed in newborn age, circumcision should not be done. During circumcision, the prepuce is cut off and a very vital tissue which is required for hypospadias repair surgery is lost. Prepuce or its layers are used for anatomical hypospadias correction surgery. In a circumcised boy, hypospadias repair becomes difficult and complication rate of hypospadias surgery is little higher.

Master K.Hadriel.Ileunga was born in Congo (Africa) in a small city. His doctor did not recognize at birth that he had a distal penile hypospadias. He underwent a circumcision in the first few days of life by a general practitioner doctor. Later his parents and doctors realized that Hadriel had a distal penile hypospadias. As he grew up in Congo (Africa) his parents worried about his hypospadias. They visited a few doctors in Congo but there was no pediatric urologist available in Congo who could do a hypospadias repair after circumcision. At this time, they learnt about Hypospadias Foundation in Navi Mumbai, India and sent an email to come and get treated under Dr A.K.Singal’s care, one of the most renowned pediatric urologists and the best Hypospadias Surgeon in India.

Finally in first week of Jan 2015, the family met Dr Singal in Navi Mumbai. On examination, Hadriel had a distal penile hypospadias without chordee. There was no prepuce as he had undergone a circumcision in newborn age. After discussing with the parents, Hadriel was taken up for Hypospadias repair surgery on 16 Jan 2015. The surgery was done using Tubularised incised plate urethroplasty – also called Snodgrass urethroplasty. The whole urethroplasty was completed in one stage. The child was discharged from hospital the next day and the hypospadias dressing was removed after 5 days. The urethral catheter was removed after one week of surgery. Hadriel passed urine in very good stream without any difficulty. After a final follow-up two week after surgery, Hadriel has gone back to Africa- his country Congo and family is very happy. Fortunately, he had an excellent result of hypospadias repair surgery even after a neonatal circumcision.

Across the borders for Hypospadias

Hypospadias is one of the most common congenital anomalies affecting more than 4,00,000 newborn babies every year across the globe. The problem is not restricted to any particular country or race. Every year, our team at Hypospadias Foundation lead by Dr A.K. Singal manages kids with hypospadias from across India and also from other countries such as Nigeria, Kenya, Iraq, Bangladesh, USA and recently Greece.

Well, the kids from Greece were a whole different story. Though originally from Greece, their father Ioannis Padadatos was employed with a company in Delhi. Master Konstantinos and Spyridon Papadatos, twin babies were born in Delhi to Maria and Ioannis were noted to have hypospadias at birth. The hypospadias was relatively severe in both the children and had associated chordee. The urethral opening was near the scrotum (testis) called Penoscrotal hypospadias. Parents were very hassled as they had never heard of the condition before and now both their newborn babies had severe variety of hyposapdias. Dissatisfied with the information given by pediatricians, pediatric surgeons and urologists in Delhi, they took up to internet for more information. They contacted Dr A.K.Singal, Pediatric Urologist & renowned Hypospadias surgeon who regularly writes articles at www.hypospadiasfoundation.com . Though they had visited the multiple doctors in delhi, what reassured them was the blogs written by dr A.K.Singal about his experience with children who had hypospadias.

After exchange of a few emails, Maria and Ioannis travelled all the way to Mumbai when the babies were 6 months old, in Nov 2013 to consult Dr A.K.Singal at Fortis Hospital in Vashi. Since the right age of surgery for hypospadias is 6 – 15 months, the parents elected to get the surgery done as soon as possible. After the blood tests, the parents again came to Mumbai in December to get the surgery done for both the kids. Master Spyridon underwent surgery on a Monday while Konstantinos underwent surgery on Tuesday. Though both had severe hypospadias and the parents were counseled that a two staged correction may be needed, the whole hypospadias surgical correction was performed in one stage using an Onlay Island Flap urethroplasty of which Dr Singal is an expert. The correction of penile curvature (chordee correction) and formation of new urinary tube (urethroplasty) were all performed in one stage.

After one more day post-surgery in Mumbai, the family travelled back to Delhi and kept in regular touch with Dr Singal via email. Dr Singal visited them one week later in Fortis Hospital in Delhi while attending a conference. Finally the catheter (urinary pipe) was removed after ten days of surgery and babies passed urine in good thick stream signifying a successful outcome in one stage. Now almost nine months after hypospadias surgery, both the babies are doing extremely well.

The family has now shifted to Doha, Qatar but they have taken a lot of India with them and most of all fond memories. We at Hypospadias Foundation are very happy to see the kids grow well and pass urine from a normal opening.

Dr Singal adds “With the advances in instruments and sutures plus better surgical techniques, we are able to do single stage correction for even severe hypospadias in most cases. Rarely we need second surgery and that too if there are complications in the first hypospadias surgery. I am happy that Maria and Ioannis trusted us for management of their children for hypospadias. They came with full faith and trust and that made my job so much easier. I will always remember their family and their beautiful kids. It was indeed a joy meeting them and knowing them. Sometimes I wonder as a hypospadias surgeon what kind of leap of faith the parents must take to travel in an unknown country to an unknown doctor and trust him/ her with the lives of their little ones. I truly appreciate their courage and faith.”

Hypospadias is one of the most common malformations in boys and affects more than 1 lakh kids in India. At Hypospadias foundation and MITR Hospital, Kharghar, Navi Mumbai, India – we see and manage more than 200 kids every year who have hypospadias and need surgery. These cases are either primary (75%) or those have failed surgery elsewhere (25%)- some of them have failed multiple surgeries elsewhere.

We strongly believe that hypospadias surgical correction should not be taken lightly or casually by any surgeons as first hypospadias surgery is the best chance which the child has. Once the first hypospadias surgery has a complication, more surgeries are needed and still the result may not be optimal. Hence, the surgeon needs to be well trained for hypospadias repair procedure and should have a very keen and passionate interest before he takes up any child up for surgery for hypospadias.

Amongst the various techniques for hypospadias surgery, one of the most popular one is Tubularised Incised Plate (TIP) urethroplasty. TIP repair was first described by Prof Warren Snodgrass and it currently constitutes 70% of all distal and midpenile hypospadias repairs across the world. Due to its universal adoption and remarkable results, it is also known as Snodgrass repair. I had the good fortune of assisting Dr Warren Snodgrass during his multiple visits to India when I was a resident in pediatric surgery at All India Institute of Medical Sciences. I keep bumping him into now and then at pediatric urology conferences, the last one of which was European Society of Pediatric urology Congress in Genoa Italy. We received the best paper award at the conference and it was nice to see Dr Warren Snodgrass applauding us.

While TIP repair or Snodgrass urethroplasty has excellent results, case selection before surgery is very important. The criteria are:

1. Distal or midpenile hypospadias
2. Mild to moderate chordee which is correctable
3. Wide pink elastic urethral plate.

In certain selected proximal hypospadias, Snodgrass repair can be used but on a personal level- a long Snodgrass repair may not be the best option in most cases. We have started using Onlay Island flap repair in most of our proximal hypospadias and all distal/ mid penile hypospadias which are unsuitable for TIP Urethroplasty.

Steps of surgery:

1. Degloving the penis and chordee correction – straightening of the curvature of the penis
2. Midline urethral plate incision
3. Neo-urethra formation on a catheter
4. Second layer coverage with either a dartos flap or spongiosum
5. Penile skin cover with Byars flap which helps in creating a midline closure on underside of penis. After the healing is finished, penis looks like just a circumcised penis. In some selected cases Prepucial reconstruction can be offered.

You can watch the video of a Snodgrass Urethroplasty for a distal penile hypospadias here.

In my experience as an expert hypospadias surgeon, while doing TIP urethroplasty everything has to be done meticulously to prevent complications. If I have to narrow down on two things which have really lessened the complications of hypospadias repair with Snodgrass urethroplasty at our centre are:

• Fashioning a wide caliber neo-meatus- so that there is no narrowing later on
• Providing a second layer cover on new urethra with either spongiosum or a dartos flap.

Master Soham’s parents stay in Latur, Maharashtra and their son was diagnosed to have a distal penile hypospadias at birth. Worried about multiple surgeries and poor outcomes for hypospadias repair- They searched for the best hypospadias surgeon on the internet and landed up in our pediatric urology clinic at MITR Hospital in Kharghar, Navi Mumbai. We did the surgery using a Snodgrass repair technique in First week of May 2014. The surgery went well and child was discharged the evening of surgery. The dressing and catheter were removed 5 days after surgery and now one month after followup the child has an excellent outcome after hypospadias repair surgery. The cosmetic appearance is excellent with a meatus at the tip of penis, straight penis and just a circumcised appearance.

Parents are also happy and overjoyed.

Last Monday was like any other Monday. My pediatric urology clinic was full with appointments and I was getting into the rhythm of seeing children with complicated urinary problems and hypospadias. A young couple walked in with twin male babies, each about 7 months old. The boys were naughty and attentive and soon were soaking in the yellow and pink and greens of my outpatient clinic. I looked at the file and asked them the pediatric urological issues for which they were seeing me that day. They said their kid had hypospadias and both of them had hypospadias infact and they wanted to see a Pediatric urologist. Now that was a shocker!! Though this was not the first time that I was seeing twin boys with Hypospadias, but it was that once in two years phenomenon. And more striking since these boys had exactly the same type of hypospadias- which was distal penile hypospadias with mild chordee. Last year I had treated two brothers with hypospadias but the age was 3 and 5 years and thus difference in age was 2 years. The elder one has a mid penile hypospadias while the younger one had a distal penile hypospadias. I suddenly remembered the dilemmas which face a Pediatric Urologist & a Hypospadiologist while treating siblings with hypospadias.

• Which boy do you treat first – plan according to age – elder first or severity wise and severe hypospadias first and minor later?

• Whether you do them the same day or one after the other or with some gap of days in between?

• How will the parents manage two babies getting operated for the same thing at the same time?

• And if you operate one baby with hypospadias first and second one a few days later- what is the effect on their minds? How do they cope up with a situation where one has undergone a hypospadias surgery and the other one is waiting. Does the second kid get scared seeing the first one in pain after surgery and undergoing hospital visits and checkups? It was a tough situation to be in – for me as a hypospadias surgeon and even more for the parents who will have to care for the children 24×7 after surgery.

After a lot of deliberation, we decided that we do the hypospadias repair one after the other but on the consecutive days at MITR Hospital & Hypospadias Foundation. We admitted the elder sibling (with more severe hypospadias) for surgery on Tuesday morning and surgery was conducted as the first case in the morning. The younger kid was admitted on Wednesday morning and underwent uneventful repair on Wednesday itself. We arranged for two beds in one room so that both of them can share their side of the story. At least here there was no scope of having a feeling of being left out. Both of them for a fact got a HYPOSPADIAS SURGERY. Recovery period after surgery was smooth and both of them were discharged on Wednesday evening. The kids came back for follow-up on the same day after a week and their catheters were removed the same day. The children pee’d and actually compared their streams and for me luckily- both had good thick straight urine streams without any complications. Deep inside, throughout the recovery period, I was a bit worried about a complication happening. Luckily, everything went well and I had two happy kids with me. Now coming back to present case at hand- where I have a set of twin babies with hypospadias. So going by my previous experience, I think we will stick to the same plan. The only advantage here is that the kids are still less than one year of age and they won’t think much about surgery. I am planning to do them on a Tuesday and a Wednesday and then send them home on Wednesday itself.

Medicine lends itself to unusual off the script events every day and as we say every patient has a story. For us at Hypospadias Foundation – we believe every child hypospadias has a story with happy ending.