Hypospadias vs Circumcision: Why Circumcision Alone Cannot Fix Hypospadias

One of the most common questions parents ask when their child is diagnosed with hypospadias is: “Can circumcision alone correct hypospadias?”

The simple answer is no. Circumcision and hypospadias repair are two very different surgical procedures, and understanding the distinction is crucial for achieving the best outcome for your child.

What is Hypospadias?

Hypospadias is a congenital condition in which the urinary opening (meatus) is located on the underside of the penis instead of at the tip. It is often associated with:

 A hooded foreskin (foreskin present on the upper side but deficient on the
underside)
 Penile curvature (chordee)
 Abnormal urinary stream

The goals of hypospadias surgery are to straighten the penis, reconstruct the urethra, and create a normal appearance.

Pic 1: Case of distal penile, proximal penile and scrotal hypospadias

What Does Hypospadias Repair Involve?

Hypospadias surgery is a reconstructive procedure that is far more extensive than a circumcision. Depending on the severity of the condition, the surgery involves the following steps:

1. Degloving

The penile skin is carefully mobilized around the shaft to release adhesions, fibrotic strands and correct any skin-related curvature.

2. Chordee Assessment

An artificial erection test is performed during surgery to assess the degree of penile curvature. The severity of chordee helps determine whether a single-stage or two-stage repair is required.

 Chordee less than 30 degrees: Usually suitable for single-stage repair.
 Chordee greater than 30 degrees: Often requires more extensive reconstruction and sometimes a staged approach.

3. Chordee Correction

Depending on the degree of curvature, correction may be achieved through:

 Dorsal tunica albuginea plication for mild curvature
 Urethral plate division
 Urethral mobilization
 Corporotomies
 Ventral lengthening procedures using dermal grafts or pericardial patches for severe curvature

4. Urethroplasty

Once the penis is straightened, the urethra is reconstructed to bring the urinary opening to the tip of the penis.

5. Circumcision

The foreskin is frequently used during hypospadias reconstruction to create the new urethra and provide skin coverage on the underside of the penis. As a result, the foreskin is usually consumed during the repair process, making circumcision a component of the surgery rather than the treatment itself.

Why Circumcision Alone Cannot Correct Hypospadias

Circumcision simply removes the foreskin. It does not:

 Correct penile curvature
 Reconstruct the urethra
 Move the urinary opening to the tip of the penis

Therefore, circumcision alone cannot treat hypospadias.

In fact, performing circumcision before a planned hypospadias repair can create significant challenges because the foreskin is often needed for reconstruction. Loss of this tissue may limit surgical options and can sometimes convert a straightforward single-stage repair into a more complex two-stage procedure.

What to Expect After Hypospadias Surgery

Following hypospadias repair:

 A dressing is placed around the penis.
 A urinary catheter is usually left in place to drain urine.
 The dressing and catheter are typically removed after 7–10 days, depending on the type of repair performed.

The final appearance is usually that of a circumcised penis because the foreskin has been used during reconstruction. The foreskin does not regrow, as it was either deficient from birth or utilized during surgery.

Attempts to reconstruct the foreskin solely for cosmetic purposes may increase the risk of complications such as tightness, scarring, or breakdown of the repair.

How is Circumcision Different?

Circumcision is a relatively minor procedure involving removal of the foreskin covering the glans penis. Common indications include:

 Recurrent phimosis
 Recurrent foreskin infections
 Balanitis Xerotica Obliterans (BXO)
 Failure of medical treatment for phimosis
 Religious or cultural reasons

Pic 2: BXO (Balanitis Xerotica Obliterans) changes noted at the tip of foreskin

Unlike hypospadias repair, circumcision generally does not require urethral reconstruction or urinary catheterisation.

The Important Exception: MIP Variant of Hypospadias

Not all hypospadias cases present with a hooded foreskin. A special subtype called the Megameatus Intact Prepuce (MIP) variant may have a completely normal foreskin.

Pic 3: MIP variant of hypospadias with complete prepuce

Because the foreskin appears normal, the diagnosis can occasionally be missed before circumcision. For this reason, surgeons should always retract the foreskin and examine the position of the urinary opening before beginning a circumcision procedure.

Take-Home Message

Circumcision does not correct hypospadias. Hypospadias is a reconstructive condition that requires correction of penile curvature and relocation of the urinary opening to the tip of the penis. In many cases, the foreskin plays an essential role in reconstruction and should be preserved until evaluation by an experienced hypospadias surgeon.

If your child has hypospadias or there is any doubt about the position of the urinary opening, consult a pediatric urologist or an experienced hypospadias specialist before proceeding with circumcision.

Hypospadias foundation is a centre located in Kharghar, Navi Mumbai, Maharashtra, India with surgeons having expertise in hypospadias repair in children and adults. We regularly manage both primary hypospadias repairs and complex cases including those with previous multiple failed repairs. A significant focus of our patient base consists of children and adults who have had failed hypospadias surgeries elsewhere. Our approach involves not just good surgical technique but also diligent pre-operative assessment, focussed post-surgery care and critical decision making for good long-term outcomes.

Dr A.K. Singal is the founder and head of hypospadias foundation, India. He is considered the best hypospadias surgeon in India and the world and has successfully treated thousands of children and adults with hypospadias with excellent results.

Dr Ashwitha Shenoy is an expert hypospadias surgeon with special interest in the field of hypospadias and pediatric urology. Both Dr Singal and Dr Shenoy strive toachieve excellent outcomes in adults and children with hypospadias. Our success rate at hypospadias foundation for all types of repairs including complex and failed repairs are more than 95%.

Hypospadias is a congenital condition where the opening of the urethra (where urine and semen exit) is not at the tip of the penis but somewhere along the underside of the penis. The location of the opening can vary from a mild one (near the tip) to a severe one (at the base of the scrotum). Nearly 70% of all hypospadias also have an associated penile curvature where the penis bends downwards, known as chordee. Hypospadias repair surgery is typically performed between 6-18 months of age. A successful hypospadias surgery aims to reposition the urethral opening to the tip of the penis, straighten the penile curvature and align the skin to give a final circumcision type of cosmetic outcome.

When it comes to fertility in men, penis and testis play a crucial role. Here is a detailed information on how hypospadias can have an impact on fertility:

1. Production of semen:

In isolated cases of hypospadias with normal testes, the sperm production is not impacted, and fertility is normal. But upto 10% of patients with hypospadias may have associated undescended testis, and this association is mostly present in severe hypospadias. Testis is the core organ for male fertility. It produces sperms and male sex hormone called as testosterone. Testosterone is essential for development of penile growth. Both sperm production and testosterone production will be impacted if the testis is not functioning fully. Hence if the person has both hypospadias and undescended testis, there may be an impact on fertility, especially if there was undescended testis on both sides. In these cases, where we have both hypospadias and undescended testis, we need to investigate for DSD (Disorder of sex development) which is seen in 15% of such cases.

2. Presence of penile curvature:

While mild chordee may not impair sexual activity, presence of chordee more than 30 degree can make sexual activity difficult and painful. Hence straightening of the penis (chordee correction) is a very crucial step in hypospadias repair.

3. Problems with ejaculation in hypospadias:

In uncorrected hypospadias with urinary opening located far below on the shaft of the penis or near the scrotum, the sperm may not deposit correctly in the vagina. Also, if the hypospadias repair has not healed properly leading to a narrow urethra (stricture urethra) or loose and bulged out urethra (severe urethral diverticulum), the semen may not ejaculate with good force. Failure of semen to reach the vagina is the cause of infertility in these cases. Hypospadias repair is essential in these patients to bring the opening to the tip of the penis and reconstruct the narrow or bulged part to allow for proper ejaculation.

4. Psychological impact:

Uncorrected Hypospadias or failed hypospadias can have psychological impact on individuals affecting their quality of life, self-esteem, social interactions when transitioning from childhood into adulthood. Adults who had hypospadias repair in childhood have reported being more timid and more isolated in childhood. In spite of successful hypospadias repair, some individuals may feel that their genitalia look different from others, leading to feeling of inadequacy and shame. This can make relationships with the opposite gender difficult and hence may be an indirect cause of infertility. Hence our advice to parents of children with hypospadias is that they should provide information about hypospadias and disclose it to their child so that they know why their penis will look different from others. This disclosure is best done during puberty between 12-15 years of age because the boys will understand the situation better at this age. Often parents bring the boys around puberty to our hypospadias centre and then we also discuss and provide full information to the boys in front of their parents. Once they are aware, accepting the situation will help them gain confidence and develop in their sexuality and also prevent any negative feelings of inadequacy.

Key message for parents

If your child has isolated hypospadias then post successful hypospadias surgery by an expert hypospadias surgeon, most likely he will not suffer from infertility in adulthood. Hence early identification, timely surgical intervention is necessary to treat the physical challenges which could impede fertility. After a successful hypospadias surgery, the ability to perform intercourse and have a normal ejaculation will significantly improve the ability to have a child.

Even after a successful hypospadias repair if an adult has difficulty conceiving, then he needs to consult a hypospadias surgeon to make sure that the previously reconstructed urethra is normal followed by a fertility specialist for further evaluation to rule out other causes of infertility. With modern surgical techniques and medical care, even a boy with severe hypospadias can lead a normal adult life and have children.

About Hypospadias Foundation

Hypospadias foundation is a specialized centre in India dedicated to the care and treatment of children and adults with hypospadias and related conditions. It is located in Kharghar, Navi Mumbai, Maharashtra. The foundation’s sole focus on a single condition hypospadias allows them to develop specialized techniques and protocols aimed at achieving the best possible outcomes for their patients. Their success rate for hypospadias correction surgery is more than 95% making them one of the top centres in the world for hypospadias repair.

Dr A.K. Singal is a highly respected and experienced Pediatric urologist and hypospadias specialist in India. He is widely recognized for his expertise in surgical treatment of hypospadias and considered as the best hypospadias surgeon in India and the world. He has developed innovative surgical techniques and treatment algorithms particularly for complex and failed cases, with strong emphasis on achieving successful functional and cosmetic outcomes.

Dr Shenoy specializes in pediatric urology and hypospadias providing advanced surgical techniques for both primary and failed hypospadias repair in children and adults. Their combined experience and shared focus on a single, complex condition contribute to the foundation’s high success rate.

Hypospadias is a common congenital condition in which the urethral opening is located on the underside of the penis rather than at the tip. Surgical repair is required to correct this and to restore both function and appearance of the penis. One of the most frequent complications following hypospadias repair is the development of a urethral fistula which is an abnormal channel that forms between the urethra and the overlying skin after surgery, resulting in leakage of urine. So, there is urine coming from 2-3 places instead of from the tip. In the hands of an expert hypospadias surgeon, the incidence of urethral fistula should be less than 5%.

Diagnosis

The diagnosis of urethral fistula is typically clinical, based on observation of urine leakage from the repaired site. Documentation of the urine stream is important in fistula after hypospadias repair to rule out presence of stricture or diverticulum in the urethra beyond the site of fistula. The number of leaks also has to be documented before planning the surgical repair. Sometimes, we also place a urethral catheter to check the calibre of urethra beyond the fistula.

Timing of Fistula Repair

It is standard practice to wait at least 6 months after the initial repair before attempting urethral fistula closure surgery, as this allows inflammation to subside, tissues to soften, and vascularity to improve. Also, small fistulas may close spontaneously hence it’s recommended to wait for atleast 6 months before planning anything.

Surgical Principles for Successful Urethral Fistula Repair

The goal of surgery is to close the urethral fistula and restore the integrity of the neourethra while minimizing the risk of recurrence. Key steps include:

• Fistula tract excision: The tract is identified, excised, and the edges are refreshed to healthy tissue.
• Layered closure without tension: Multi-layered closure is crucial, typically involving the urethral mucosa, spongiosum (if available), dartos fascia, local tissues and skin. A hypospadias surgeon must make sure that the layers are not under any tension.
• Use of vascularized tissue: An intervening vascularized tissue flap (such as dartos fascia or tunica vaginalis in proximal fistula) is often placed between the urethra and skin to prevent recurrence.
• Fine absorbable sutures: Used to minimize tissue reaction and foreign body response.
• Catheterization: A urethral catheter is left in place for 7-10 days postoperatively todivert urine and protect the repair.

Techniques for Urethral Fistula Repair Surgery

Urethral Fistula closure can be performed in various ways.

• Simple closure: Reserved for small, well-defined fistulas with healthy surrounding tissue. Remember in these repairs also a layered closure with well vascularised tissues is important. One can utilize dartos or tunica vaginalis flap for additional coverage and vascular support.
• V-Y Flap Repair: In large fistulae, we often use a skin advancement flap from surrounding skin to provide non-overlapping suture lines. The flap can be laterally based or proximally based.
• Complex repairs: For large or recurrent fistulas, entire urethral reconstruction may be required which is done using local flaps or oral mucosa graft. Staged repair may be required in fistula cases with unhealthy urethra beyond the site of fistula.

Postoperative Care

Meticulous postoperative care is pivotal to ensure successful healing:

• Maintain catheter patency, monitor for obstruction or kinking.
• Keep the surgical site clean and dry. Gentle wound care as instructed by the surgical team.
• Monitor for signs of infection: swelling, redness, discharge, or fever.
• Avoid strenuous activity, straining or pressure on the site until fully healed.
• Follow up as recommended with your surgical team for wound checks and early detection of complications.

Prevention of Urethral Fistula Formation

Preventing fistula formation is an important aspect of hypospadias surgery

• Use of meticulous surgical technique with tension-free, multi-layered closure.
• Ensuring well-vascularized tissue coverage over the neourethra.
• Surgical site care and managing infection if any in the post operative period
• Make sure the passage beyond the fistula site is not narrow and of adequate calibre
• The meatus should be checked and if found to be narrow, meatotomy should be performed.

Prognosis and Outcomes

With appropriate timing and technique, most urethral fistulas can be successfully repaired. Prognosis depends on several factors:

• Location of the fistula site: Fistula far away from the coronal region can be repaired by simple closure.
• Tissue quality: Healthy, non-scarred tissue improves the likelihood of long-term closure.
• Number of previous repairs: Each additional surgery slightly reduces the success rate due to increasing tissue scarring and reduced vascularity.
• Surgeon’s experience: Experienced pediatric urologists have higher success rates for complex repairs.

Conclusion

Urethral fistula is the most common complication after hypospadias repair, but with proper diagnosis, patient selection, and surgical technique, most cases can be effectively managed. Families and patients should be reassured that while the development of a fistula is distressing, it can often be successfully treated, and most children go on to have normal urinary and functional outcomes. If you suspect a urethral fistula or have concerns about post-hypospadias surgery care, it is important to consult a pediatric urologist or specialized hypospadias surgery team for
individualized assessment and management.

About Hypospadias Foundation

Hypospadias foundation is a centre located in Kharghar, Navi Mumbai, Maharashtra, India with best surgeons having expertise in hypospadias repair in children and adults. We regularly manage both primary hypospadias repairs and complex cases including those with previous multiple failed repairs. A significant focus of our patient base consists of children and adults who have had failed hypospadias surgeries elsewhere, including persistent fistulas. Our approach involves not just good surgical technique but also diligent pre-operative assessment, focussed post-surgery care and critical decision making for good long-term outcomes.

Dr A.K. Singal is the founder and head of hypospadias foundation, India. He is considered the best hypospadias surgeon in India and the world and has successfully treated thousands of children and adults with hypospadias with excellent results.

Dr Ashwitha Shenoy is an expert hypospadias surgeon with special interest in the field of hypospadias and pediatric urology. Both Dr Singal and Dr Shenoy strive to achieve excellent outcomes in adults and children with hypospadias. Our success rate at hypospadias foundation for all types of repairs including complex and failed repairs are more than 95%.

Hypospadias is a condition seen in 1 in 150 to 200 newborn boys. Surgical repair is the primary treatment for hypospadias, aiming to reposition the urethral opening to the tip of the penis, straighten any abnormal curvature and to improve the overall appearance of the penis. Like any other surgery, complications can occur even after hypospadias repair. The common complications which occur are urethrocutaneous fistula, meatal stenosis, glans dehiscence and rarely urethral diverticulum or urethral stricture. Among this the most common and notorious complication is the urethral fistula.

Urethrocutaneous fistula refers to the development of an abnormal opening between a newly constructed urethra and the skin on the underside of the penis. When this occurs the child or the adult will have more than one urine stream. There will be one stream from the tip of the penis (the newly created opening) and the other stream or leak of urine from the fistula site. The leaking of urine from the fistula site tends to fall on the legs or can wet the clothing causing inconvenience to the children and the adult. In our centre, we see lot of children coming for urethral fistula treatment after first surgery somewhere else like the case below.

Post hypospadias surgery fistula can occur due to multiple reasons. Some of them are as follows:

1. Intraoperative factors:

a. Poor blood supply: Poor blood supply also called as ischemia is one of the most common factors that can severely impair and delay tissue healing. The process of wound healing is complex and heavily relies on the continuous supply of essential nutrients along with oxygen via the blood stream. During urethroplasty if the blood supply of the tissues is poor then fistula formation can occur post-surgery due to poor healing.

b. Inadequate tissue closure: During urethroplasty, we must take care that there should be a watertight closure of the newly reconstructed passage. And this urethral passage should be reinforced with multiple layers of tissues such as local tissues or dartos flap so that the risk of fistula formation decreases. Gaps in the urethral closure with deficient overlying tissue layers can increase the risk of fistula formation.

c. Tight closure of tissues: The urethroplasty and overlying tissue closure in hypospadias should never be under tension. If the tissue closure is tight then the vascularity is affected and can cause ischaemia of the tissues leading to skin necrosis and fistula formation.

d. Narrow or stenosed urethra: The newly reconstructed urethra in hypospadias should be of good calibre. If the urethra becomes narrow, then there can be increased pressure within the urethra proximal to the narrow segment leading to a weaker point which gives away causing urine leaking from this pointwhich becomes a fistula.

e. Type and severity of hypospadias: Severe hypospadias or complex hypospadias is usually associated with severe penile curvature along with urinary opening situated far from the head of the penis. Longer urethral reconstruction is inherently more complex with higher risk of complications and hence higher chance of fistula formation compared to milder forms of hypospadias.

f. Fibrotic or unhealthy tissues: Fibrotic tissues are associated with poor blood supply and using such tissues for urethral reconstruction can be disastrous with higher possibility of dehiscence and fistula formation.

g. Surgeon experience: The risk of fistula formation will be higher at a centre performing very few hypospadias repairs compared to a centre performing more than 50-60 repairs every year. The technique, tissue handling etc gets better only once the surgeon performs more than 50 hypospadias surgeries every year.

2. Post operative factors:

1.Infection: If the operated hypospadias site gets infected in the post-surgery period, then there is a possibility of dehiscence at the site of infection which in turn can cause fistula formation.

2.Poor nutrition: Optimal nutrition is not just beneficial but fundamental for wound healing. Deficiency in key nutrients can cripple the body’s ability to repair itself leading to weakened tissue, increased infection risk and ultimately wound breakdown and higher chance of fistula formation

3.Presence of constipation: Constipation can indirectly contribute to wound breakdown. Straining to pass stool can put pressure on the penile area and can put undue stress on the delicate tissues and new sutures which can give away and cause fistula formation.

Inspite of the best efforts of the hypospadias surgeon, fistula can occur after hypospadias repair. Even if fistula occurs, there is a possibility that the fistula can close spontaneously. At Hypospadias Foundation, we wait for 6 months to assess the same and if it does not close then surgery in the form of fistula closure may be required. Before urethral fistula closure it is mandatory to check the urinary passage beyond the site of fistula. If the passage beyond the site of fistula is narrow, then simple urethral fistula closure may not suffice, and reconstruction of the entire distal passage (distal urethroplasty) may be necessary.

Hypospadias foundation is a centre located in Kharghar, Navi Mumbai, Maharashtra, India with surgeons having expertise in hypospadias repair in children and adults. We regularly manage both primary hypospadias repairs and complex cases including those with previous multiple failed repairs. A significant focus of our patient base consists of children and adults who have had failed hypospadias surgeries elsewhere, including persistent fistulas. Our approach involves not just good surgical technique but also diligent pre-operative assessment, focussed post-surgery care and critical decision making for good long-term outcomes.

Dr A.K. Singal is the founder and head of hypospadias foundation, India. He is considered the best hypospadias surgeon in India and the world and has successfully treated more than thousands of children and adults with hypospadias with excellent results.

Dr Ashwitha Shenoy is an expert hypospadias surgeon with special interest in the field of hypospadias and pediatric urology. Both Dr Singal and Dr Shenoy strive to achieve excellent outcomes in adults and children with hypospadias. Our success rate at hypospadias foundation for all types of repairs including complex and failed repairs are more than 95%.

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/

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 the most common urological birth defect occurring in upto 1/150 newborn boys, which measures upto almost 100,000 (1 Lakh) new cases every year. While most of the cases are not hereditary or genetic, 6-8% of hypospadias cases have family history of hypospadias or associated genetic disorders. In the current era and in cities, most of these children are referred to pediatric urologists or surgeons in early childhood and receive timely treatment for hypospadias. This was not true 20 years back or even now in many parts of the world. Hence, there are a large number of adults living with hypospadias across the world either unrepaired or some who have failed hypospadias surgery in childhood. In India alone, there are an estimated 5 lakh adults who have either not received hypospadias surgery or have failed hypospadias surgery in their earlier years and their families or they themselves have given up.

Every year, we receive adults from many countries in South East Asia and rest of the world who travel to India to Hypospadias Foundation to find treatment for their Hypospadias problem. Recently, a young man travelled from Nepal for hypospadias treatment. We would like to share the story.

Reaching Hypospadias Foundation:

Mr N.S. was born with hypospadias and was diagnosed soon after birth. Due to lack of knowledge and pediatric urology/ hypospadias specialists in Nepal, his parents could not get him treated for hypospadias in childhood. He grew up to be a smart boy and completed his graduation and got employed with an infrastructure company in Nepal. But somewhere at the back of his mind he had this nagging doubt about treatment of his hypospadias issue. He kept on searching whether he can get treatment with good results for hypospadias at the age of 23 years but no one gave him a satisfactory answer. Finally he contacted Hypospadias Foundation at Navi Mumbai, India- a team of hypospadias surgeons led by Dr A.K.Singal and Dr Manish Dubey. He sent his medical records by email and also some pictures. After an electronic opinion, he finally travelled to Navi Mumbai in September 2014.

Examination:

Mr N.S. was examined by Dr A.K.Singal, Pediatric urologist and expert Hypospadias surgeon in Hypospadias Clinic at Hypospadias Foundation, Navi Mumbai, India. He was found to have distal penile hypospadias with mild chordee. No previous surgery had been done. The midline raphe of the penis was misaligned to one side causing a slight bend in the penis also to one side called penile torsion. N.S. was counselled for surgery as well post-op recovery and underwent distal penile hypospadias repair surgery (urethroplasty) the next day.

Hypospadias Repair surgery:

Since it was a case of primary hypospadias and there was no previous surgery done, the urethral plate was still preserved well. We planned to do a single stage TIP repair (Tubularised Incised plate urethroplasty or Snodgrass repair). The new urinary tube (urethra) was made over 12 Fr silicon catheter and covered with two additional layers for secure healing and prevent fistula. First layer was with corpus spongiosum called spongioplasty and second was with dartos from foreskin on the top of penis. Finally excess foreskin on top was excised imparting a circumcised look to the penis. N.S. was discharged the day after surgery on antibiotics, analgesics (painkillers), antacids and antispasmodics. Additionally a medicine was given to decrease erections temporarily. One week later, we removed the dressing in clinic and finally the catheter was removed on day 10. N.S. had some pain initially on passing urine but within 2-3 days he was passing urine normally from the tip of penis. There was an issue with delayed healing of skin on underside of his penis which finally healed completely in 2 months. He has been passing urine normally and came to see us at 6 months follow-up after surgery this week (18^th March 2015) and was extremely happy with the result of hypospadias repair surgery. He has healed well with a single stage surgery and does not require any further surgery. He is planning to start seeing girls now and get married soon. We have given him a clearance to go ahead with marriage and send him our best wishes from Hypospadias Foundation.