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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.

48-year male presented to us with complaints of passing urine from scrotal region since childhood.  He had undergone three hypospadias surgeries elsewhere in the past but still he had multiple urethral fistulas on the underside of the penis. 8 years ago, he developed acute retention of urine, likely due to a suspected urethral stricture. A suprapubic catheter (SPC) was inserted and since then he was on SPC for urine drainage. He visited multiple centres across India from Delhi to Bangalore to Chennai in hope of cure, but everyone dissuaded him for further surgery. Finally, he visited hypospadias foundation for an opinion.

On examination in the OPD, he was primarily draining urine from the SPC. We could see three urinary openings – one meatus was at the penoscrotal junction, and he also had a scrotal and a mid-penile fistula. On clamping the SPC, we checked his urine stream – the stream was poor with a uroflowmetry flow rate of 2.5ml/second and there was spraying of urine.

A retrograde urethrogram was done which showed narrow distal urethra with diverticulum in the rest of distal urethra upto the membranous part of urethra.

We planned a cystoscopy assessment of the proximal urethra following which he was planned for a staged oral mucosa graft urethroplasty.

Stage 1 Oral Mucosa graft urethroplasty:

Cystoscopy showed urethral diverticulum from the penoscrotal region to the membranous urethra. The distal urethra was found to be strictured – we were not able to pass the cystoscope.

Surgery was started by taking a stay stitch over the glans using 4-0 prolene. Complete degloving was done and chordee was checked- no residual chordee was observed. Urethral diverticulum was laid open till normal urethral mucosa was identified. Unhealthy distal fibrotic strictured urethra was removed completely. Proximal diverticulum site was trimmed and proximal urethroplasty done upto the penoscrotal region with 5-0 PDS over a 14Fr silicone catheter. Distal urethral bed was prepared for placement of oral mucosa graft. Glans wings was widely raised.

Oral mucosa graft was harvested from inside of both the cheeks measuring a total of 11cm X 2cm (6cm and 5cm). Graft was defatted slightly and quilted in place using 5-0 vicryl. Pressure dressing was applied, and the catheter was fixed to glans stitch. Dressing and catheter were removed after 10 days.

Graft uptake 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 healthy. At stage 2, graft edges were marked. Local anaesthesia (lignocaine with adrenaline) was infiltrated at the marked site. U shaped incision was given and deepened till the corpora. Urethroplasty was done over a 14Fr silicone catheter with 5-0 Vicryl in 2 layers. Local dartos flaps were used for second layer coverage. Skin was closed in 2 layers and dressing was done. Suprapubic cystostomy was done using 14 Fr malecot’s catheter. Dressing inspection was done on post operative day 4 and every 4^th day thereafter. During every dressing change betadine wash was given and re dressing was done. Per urethral catheter was removed on post operative day 14 and suprapubic catheter was removed on post operative day 21. Patient was passing urine in good stream without pain or leak after catheter removal. At his final checkup, 6 months after surgery- the cosmetic result was good, and the patient was passing urine from the glanular meatus in good stream.

Never give up hope even if multiple hypospadias surgeries have failed

Hypospadias treatment in adults especially if previous surgeries have been unsuccessful, is a difficult task. The complexity of the condition and the potential for complications can often necessitate a staged repair, maybe even in 3 stages. A lot of adults in this century, underwent surgery as children way back in the past and some of them did not get good results even after multiple hypospadias surgeries. With advancing knowledge and expertise, the results of hypospadias repair (urethroplasty) in such cases have improved.

Reasons for multiple surgeries in adults with hypospadias may include:

1. Development of complications: The common complications which can occur after hypospadias repair are urethral strictures, fistulas, diverticulum, hairy urethra or residual chordee. These may require additional surgical intervention.
2. Unsatisfactory cosmetic results: The patient may be unhappy with the appearance of their penis following the initial surgery.

An adult with multiple failed hypospadias surgeries, generally has no normal hairless penile skin left for hypospadias repair. Hence in such patients, it may be better to use skin from inside the mouth for making the new passage. The skin is taken from inside of cheek or lips and is called oral mucosa. The defect heals very fast and generally without complications. The oral mucosa graft adapts to penile location very well and has great long-term results in redo hypospadias repairs. While some of these cases are suitable for a single stage surgery, some may require two stage surgery depending on the severity of the defect. Nonetheless, Oral Mucosa Graft Urethroplasty remains a great option with best long-term results for children and adults with Failed Hypospadias.

It’s important to note that multiple surgeries can be physically and emotionally demanding. It’s essential to have a strong support system in place and to communicate openly with your hypospadias surgeon about your concerns, experiences and your expectations. If you have undergone multiple hypospadias surgeries, it’s crucial to consult a qualified hypospadias surgeon who can assess your condition and recommend the best treatment plan.

At Hypospadias Foundation in India, Dr Singal and his team offer specialised treatments with best hypospadias surgery results in the world. Children and adults from more than 20 countries such as Dubai & UAE, Bahrain, Iran, Iraq, Afghanistan, Saudi Arabia, Pakistan, Bangladesh, Malaysia, Tanzania, Nigeria, Congo, Ethiopia, Kenya, Nepal, Indonesia, Egypt, Jordan etc come for treatment at our foundation. It is indeed heartening to see them go back with final cure from hypospadias.

Dr A K Singal is regarded as the best hypospadias surgeon in India and in the world for treating children and adults with hypospadias. If you are looking for a highly skilled and experienced pediatric urologist and hypospadias surgeon for yourself or your child, then Dr Singal is an excellent choice.

Dr Ashwitha Shenoy is an expert pediatric surgeon with a special interest in pediatric urology and hypospadias. Dr Singal and Dr Shenoy’s collaboration allows them to offer advanced surgical techniques and comprehensive care for patients.