best Hypospadias surgeon India – Hypospadias Foundation

March 03 2026

Single-Stage Repair for Proximal Penile Hypospadias Using Split Prepuce Onlay Flap (Singal–Shenoy Repair)

A 2-year-2-month-old male child presented to the Hypospadias Foundation clinic with the complaint of passing urine from the penoscrotal region since birth. On clinical evaluation in the outpatient department, the child was noted to have moderate chordee with the urethral meatus located in the penoscrotal region, consistent with Severe Hypospadias. On genital examination, the penile size was small, with a stretched penile length (SPL) of 25 mm and glans diameter (GD) of 10 mm.

Given the small penile size, an hCG stimulation test was performed to evaluate the underlying hormonal status. The test demonstrated a good increase in testosterone levels following hCG administration, but insufficient conversion of testosterone to dihydrotestosterone (DHT), suggesting impaired androgen conversion. This was suggestive of 5 Alpha reductase deficiency.

Based on these findings, the child was started on topical Dihydrotestosterone (DHT) gel therapy. The treatment was continued for two months. Following DHT gel application, there was a significant improvement in penile size, with the glans diameter increasing to 15 mm. After discontinuation of DHT therapy, hypospadias repair surgery was planned two months later to allow stabilization of local tissue effects.

Post-therapy examination revealed improvement in penile size, and the urethral meatus appeared to be located in the proximal penile region rather than the penoscrotal region.

Pic 1: Clinical examination in the operation theatre showed proximal penile meatus. Complete degloving done.

Operative Procedure

The surgery was initiated by placing a stay suture on the glans using 5-0 Prolene suture. The degloving incision was marked, and local anesthesia with Lignocaine and adrenaline was infiltrated along the marked incision line. A deep penile degloving was performed. Following degloving, chordee assessment was carried out using the Artificial Erection Test. The curvature was measured and noted to be less than 30°. Correction of the chordee was achieved using 12-o’clock dorsal Tunica Albuginea Plication (TAP). After plication, the artificial erection test was repeated and no residual chordee was observed.

Given the intraoperative findings, a single-stage repair was planned. As the case involved a long urethroplasty segment with a narrow urethral plate and a flat glans, a modified Preputial Onlay Flap Repair was selected. This technique is particularly suitable for hypospadias with mild chordee which is correctable without division of urethral plate, narrow urethral plate, and shallow or flat glans.

Pic 2: An Artificial Erection Test was performed to assess penile curvature. A mild distal chordee of less than 30° was noted. Chordee correction was carried out using 12-o’clock dorsal Tunica Albuginea Plication. Following plication, the artificial erection test was repeated and no residual chordee was observed.

The required flap length was measured. The dorsal prepuce was divided in the midline, and the right half of the prepuce was used to raise the onlay flap. A stay suture using 6-0 PDS suture was placed at the edge of the flap for traction. The flap width was maintained at approximately 6 mm. The flap, along with the underlying dartos tissue, was carefully mobilized until the desired reach was obtained. A midline relaxing incision was made in the urethral plate to widen it. Urethroplasty was then initiated by placing three interrupted sutures at the proximal end of the repair at the 7, 6, and 5 o’clock positions. This was followed by a continuous edge-to-edge anastomosis between the preputial onlay flap and the margins of the urethral plate, completing the urethral reconstruction.

Pic 3: The required length of flap was measured and split prepucial flap was raised with good dartos tissue

Fig 4: Glans wings raised and urethroplasty done over 7Fr infant feeding tube. Right dartos flap raised and sutured over the urethroplasty with 6-0 PDS.

Pic 5: Split prepucial flap sutured to the edge of the urethral plate. Dartos flap spread fixed on either side of suture line

Pic 6: Modified split prepucial onlay flap repair complete

Pic 7: Cosmetic result at 1 month after surgery

Pic 8: Appearance at 6 months after surgery with good urine stream

Single-Stage Repair of Proximal Penile Hypospadias with Split Preputial Onlay Flap Urethroplasty

Proximal Penile Hypospadias is a congenital condition in which the urethral opening (meatus) is in the proximal penile region rather than at the tip of the glans. Surgical management involves correction of penile curvature (chordee correction) and reconstruction of the urethra to bring the urinary opening to the tip of the penis. Early surgical correction is important to preserve normal urinary function and future sexual function.

Most pediatric urologists and hypospadias surgeons prefer a two-stage repair for proximal penile hypospadias, particularly in cases where:

1. Chordee is significant
2. The urethral plate is narrow or of poor quality
3. A long segment urethral reconstruction is required

However, a single-stage repair may be considered when the chordee after penile degloving is mild. In the present case, intraoperative assessment showed chordee of less than 30°, which allowed us to proceed with a single-stage reconstruction.

For urethral reconstruction, we used a modified preputial onlay flap urethroplasty (split preputial onlay flap). This technique is particularly useful in cases where chordee is mild, but the urethral plate is narrow or suboptimal. In this method, a well-vascularized flap from the dorsal prepuce is mobilized and sutured onto the urethral plate to form the neourethra. Preservation of the urethral plate combined with the addition of vascularized tissue helps create a wide and well-supported urethral channel.

This type of repair is technically demanding and generally yields good outcomes only when performed by experienced surgeons. The main advantage of this technique is the creation of a wider urethral lumen, which may reduce the risk of Urethral Stricture in the future.

However, potential complications may still occur, including:

 Meatal Stenosis
 Urethral Diverticulum
 Urethrocutaneous Fistula

Careful patient selection, meticulous surgical technique, and adequate postoperative care are essential to achieve optimal outcomes in single-stage proximal hypospadias repair.

About Hypospadias Foundation

The Hypospadias Foundation, located in Kharghar, Navi Mumbai, Maharashtra, India, is recognized as one of the best hospitals centers for Hypospadias Surgery treatment in India and worldwide. Patients travel to the Hypospadias Foundation not only from across India but also from Asia, the Middle East, Africa, Europe, and North America seeking expert care for primary hypospadias repair, failed hypospadias surgery, and complex redo hypospadias cases.

Over the past 18 years, the Hypospadias Foundation has performed more than 5000 hypospadias surgeries every year, making it one of the highest-volume hypospadias centres in India and the world. With a complication rate of less than 5%, the centre has achieved
excellent surgical outcomes and international recognition in hypospadias management.

Expert Hypospadias Surgeons in India

Dr A. K. Singal is well experienced and respected hypospadias surgeon, and is rated as the best hypospadias surgeon in India and the world. He has dedicated his career to treating children and adults with hypospadias, including complex and failed repairs. His expertise in advanced hypospadias surgical techniques and reconstructive pediatric urology has helped thousands of patients achieve successful outcomes.

Dr Ashwitha Shenoy is an expert pediatric surgeon with a special interest in pediatric urology and hypospadias surgery. She works closely with Dr. Singal in managing both primary hypospadias cases and complex redo surgeries.

Together, Dr. Singal and Dr. Shenoy provide world-class hypospadias treatment in India, combining advanced surgical techniques, high surgical volume, and meticulous postoperative care. Their collaborative approach has resulted in excellent outcomes for children and adults undergoing hypospadias repair. Today, the Hypospadias Foundation in Navi Mumbai is widely regarded as a global referral centre for hypospadias surgery, helping patients achieve normal urinary function, improved cosmetic outcomes, and better quality of life.

January 01 2026

Failed hypospadias with urethral stricture and fistula – Two stage oral mucosa graft urethroplasty

A 6-year male child presented to Hypospadias foundation OPD after 4 failed hypospadias surgeries in Australia. After the first surgery in Australia, he had complete breakdown of the newly reconstructed urethra. He further underwent redo surgery in 3 stages, but it was unsuccessful. Even after a redo surgery, child was unable to pass the urine from the distal penile meatus. On examination in the Hypospadias Foundation OPD, the urinary opening was at the midpenile region. The distal passage was completely strictured. There was no obvious chordee on examination. We counselled the parents that the entire repair needs to be done again in 2-3 stages.

At the start of hypospadias surgery, we performed cystoscopy. The urethra proximal to the midpenile meatus was normal. Scope could not be negotiated into the distal urethra. Chordee was assessed and there was no residual chordee. We decided to proceed with two stage oral mucosa graft repair since there was no residual chordee.

Glans stitch was taken with 4-0 prolene. The distal urethra was laid open and noted to be completely stenosed. Unhealthy fibrotic urethra was excised completely. Oral mucosa graft was harvested from the right cheek of size 5x2cm. Graft was placed on the ventral raw area and quilted thoroughly on the corpora with 6-0 PDS.

After stage 1, healing was good. Steroid massage was started 3 weeks after surgery and was continued for 5 months. There was 100% graft uptake. Second surgery was planned 8 months after stage 1 when graft was soft and pliable.

Second stage repair (Urethroplasty)

Local anesthesia, lignocaine with adrenaline was injected at the edges of the graft. Graft was incised at the margin keeping a width of 18mm. Graft was tubularized over a 7Fr infant feeding tube (IFT). Second layer was closed with local tissues. Glans wings were widely mobilized. Dartos flap was raised from the left side and sutured over the urethroplasty with 6-0 PDS. Glansplasty was done with 5-0 vicryl and glans epithelium was closed with 6-0 PDS. Skin was closed in 2 layers with 6-0 PDS and 6-0 vicry rapide.

Dressing change was done on day 7 and catheter was removed on post operative day 12. After catheter removal, the child was passing urine in single straight stream with no pain or leak.

Picture 1: On examination, the meatus was in the midpenile region. Chordee was assessed during stage 1, there was no residual chordee

Picture 2: Pre surgery urine stream, passing urine from midpenile region with no flow from the distal penile meatus.

Picture 3: Distal urethra was laid open and noted to be completely stenosed.

Picture 4: Unhealthy urethra excised, glans wings widely raised for placement of oral mucosa graft

Picture 5: Oral mucosa graft harvested from right cheek, sutured on the ventral side and quilted to the underlying corpora with 6-0 PDS.

Picture 6: At 3 weeks after stage 1 OMG, the graft was examined. There was 100% graft uptake

Picture 6: Follow up at 6 months after surgery

Picture 7: Graft was soft and supple at 8 months after stage 1. Graft edges were incised keeping a width of 18mm for urethroplasty

Picture 8: Urethroplasty was done over 7Fr infant feeding tube. Dartos flap from the left side was raised and sutured over the urethroplasty.

Picture 9: Urethroplasty and glansplasty was completed. Catheter removal was done on post operative day 12

Picture 10: Cosmetic result and urine stream at 6 months after stage 2 urethroplasty

Surgery for failed hypospadias – stricture and fistula – Two stage oral mucosa graft repair

Failed hypospadias with stricture and fistula – Two stage oral mucosa graft urethroplasty

Urethral stricture and urethrocutaneous fistula are two well-recognized complications following hypospadias repair. A urethral stricture refers to narrowing of the reconstructed urethra due to scarring. This obstruction is one of the important factors contributing to fistula
formation.

In the above-mentioned case, the child developed distal urethral narrowing and was unable to pass urine through the distal penile meatus. As a result, the urethra opened in the mid- penile region, allowing urine to drain from the bladder. Since urine preferentially drained through the mid-penile opening, flow across the distal urethra ceased, leading to progressive stenosis of the distal segment. Over time, this resulted in narrowing of the entire distal urethra.

The most common causes of urethral stricture following hypospadias surgery include ischemia of the neourethra due to poor vascularity, excessive tension on the reconstructed urethra, and postoperative infection. Urethral strictures occurring after hypospadias repair differ significantly from non-hypospadias–related urethral strictures. In such cases, urethral dilatation is usually ineffective, and repeated dilatations may further worsen the scarring and narrowing.

Management of post-hypospadias urethral stricture typically requires replacement of the narrowed segment with healthy tissue. This is achieved using either oral mucosal grafts (such as buccal mucosa) or well-vascularized local skin flaps to adequately widen the urethra and restore normal urinary flow.

Complications following hypospadias repair are best managed by a trained and experienced pediatric urologist, particularly one with expertise in failed and complex hypospadias cases. Multiple previous surgeries significantly increase the complexity of subsequent repairs. In such situations, staged surgical reconstruction often provides better functional outcomes, improved cosmesis, and more durable long-term results.

At the Hypospadias Foundation India, children and adults from more than 30 countries worldwide seek treatment for hypospadias and its complications. The surgical team, led by experienced surgeons Dr. A. K. Singal and Dr. Ashwitha Shenoy, specializes in managing complex, multistage, and failed hypospadias repairs. Dr A.K.Singal is considered the best hypospadias surgeon in the world especially for children or adults who had a failed hypospadias surgery earlier. With a deep understanding of the nuances involved in challenging hypospadias surgery, the Hypospadias Foundation offers a dedicated and specialized approach for patients requiring advanced reconstructive care.

January 01 2026

Can there be urinary problems after hypospadias repair?

Hypospadias is a condition in which the urinary opening is located on the underside of the penis. Surgery is required to correct this condition. Because the surgery involves reconstruction of the urethra there may be a change in urinary patterns or some urinary complications to occur during recovery. The body needs time to heal and adapt to the newly formed urethra.

Urinary issues may occur while the catheter is in place or after catheter removal.

Short-term recovery issues (with catheter in situ)

Children may experience the following during the post-operative period while the urinary catheter is in place:

1. Bladder spasms
These may feel like sharp cramping pain in the lower abdomen or a sudden urge to urinate. Bladder spasms are commonly caused by irritation of the bladder lining from the urinary catheter. To reduce discomfort, anticholinergic medications are routinely prescribed after surgery, and the dose may be increased if symptoms persist.

2. Leakage around the urinary catheter
Some urine may leak from the tip of the penis around the catheter. This is usually normal if urine is draining well through the catheter and there are no signs of blockage.

3. Blood in the urine
A few drops of blood may occasionally be seen in the urine while the catheter is in place. This is generally expected in the early post-operative period and usually resolves on its own.

4. Whitish material in urine: Sometimes there may be whitish flakes in otherwise clear urine. These oay be due to mucus, minerals or bladder lining cells. Doctor may ask to increase water intake. If the urine is clear, there is smell or pus, nothing needs to be done except increasing hydration.

If urinary problems persist or appear months after hypospadias surgery, further evaluation may be required. Some children may develop symptoms after few months of hypospadias repair which can be poor urinary stream, urine leakage, painful urination, or difficulty emptying the bladder. These issues may indicate a late surgical complication of hypospadias repair.

Common surgical complications after hypospadias repair

1. Urethrocutaneous fistula
A urethrocutaneous fistula or also known as urethral fistula is a small opening along the reconstructed urethra that allows urine to leak through the skin. Parents may notice urine coming out from two or more openings during urination. There are high chances that some fistula specially if they are away from head of penis and the new urethra is not tight – they may close by themselves. Hence, we observe the fistula for up to 6 months, as some may close spontaneously. If it does not close on its own, surgical correction may be required.

2. Meatal stenosis
Meatal stenosis occurs when the new urinary opening at the tip of the penis becomes narrow due to scar tissue formation. Symptoms include a very thin urinary stream, straining during urination, or pain while passing urine. On examination, the meatus appears visibly narrow. The diagnosis can be confirmed by a video of stream and uroflowmetry. Sometimes a ultrasound may show incomplete bladder emptying. In the early post-operative period (within 1–2 months), meatal calibration may be helpful. If narrowing persists beyond 3 months, a meatotomy may be required.

3. Urethral stricture
In urethral stricture, the reconstructed urethra becomes narrowed along its length. The length of stricture may be really short or it can extend for a longer length. This can lead to difficulty passing urine, straining, frequent urination, poor stream, or recurrent urinary tract infections. Urethral strictures usually require repeat surgery to reconstruct or replace the urethra. Repeated dilatation is not recommended, as it does not provide lasting relief and may worsen the condition.

4. Urethral diverticulum
In some cases, a pouch (diverticulum) forms along the reconstructed urethra, causing it to bulge during urination. This can lead to urine collecting in the pouch, resulting in post-void dribbling or leakage after urination. Parents may notice a swelling on the underside of the penis while the child urinates. If the diverticulum is significant or causes symptoms, redo urethroplasty may be required.

Management approach
If a child is in the early recovery phase (first 2–3 weeks after surgery), symptoms may improve with anti-edema medications and urethral calibration. However, if urinary symptoms persist beyond 2–3 months, close monitoring and further surgical intervention may be necessary.

About Hypospadias Foundation
At Hypospadias Foundation, we treat children and adults from across India and around the world who present with urinary problems after hypospadias surgery. Each case is evaluated individually with appropriate investigations, and the final decision regarding the type of repair is made intra-operatively, taking all relevant factors into consideration.

Dr A.K. Singal is considered the best hypospadias surgeon globally, not just in India, due to his high volume of successful complex cases and specialized focus in hypospadias. Dr. Singal has successfully treated thousands of children and adults with hypospadias, including severe, proximal, and redo cases that require advanced surgical expertise. What sets Dr. A. K. Singal apart is his deep understanding of post- hypospadias complications, such as fistula, meatal stenosis, urethral stricture, and diverticulum. Many patients who have undergone unsuccessful surgeries elsewhere seek his care for definitive correction. He emphasizes long-term outcomes, not just immediate surgical success, with careful follow-up and individualized planning.

Dr. Ashwitha Shenoy is a dedicated pediatric urologist and an integral member of the clinical team at Hypospadias Foundation, where she specializes in the evaluation and management of children with hypospadias and related urogenital conditions. She is actively involved in the pre-operative assessment, surgical care, and long-term follow-up of children undergoing hypospadias repair. Contacting the Hypospadias Foundation:

Contact Form for Hypospadias Foundation

Please fill all clinical details and upload pictures and clinical summaries (if available)

December 12 2025

Failed Hypospadias with distal penile fistula – Single stage redo urethroplasty

Mast B.E, 14-year male from Mumbai had undergone two unsuccessful hypospadias repairs at another hospital in the past. He presented to Hypospadias Foundation with complaints of passing urine from two sites, which is from the tip and from the distal penile region. On clinical examination, there was an eccentric subcoronal fistula with a thin glans bridge separating it from the glanular meatus. There was some residual skin on the dorsal side. The urine stream was spraying as shown in the photo below

Picture 1: On clinical examination, there was an eccentric distal penile fistula with thin glans bridge separating it from the glanular meatus

Picture 2: Urine stream was poor with spraying of urine.

He was planned for single/ two stage repair depending on the degree of chordee, status of native urethra and quality of urethral plate. Cystoscopy was noted to be normal. Chordee assessment showed no residual chordee. The thin glans bridge between the meatus and the fistula was divided. The urethral plate was noted to be wide with no scarring. Considering all the above factors he was planned for single stage repair – simple tube urethroplasty or Glans Approximation Procedure was decided.

Picture 2: Artificial erection test showed no residual chordee. Urethral plate was noted to be wide and healthy.

Stay suture was taken on the glans with 4-0 prolene. Complete degloving was done. Artificial erection test showed no residual chordee. Glans wings were marked and raised. Urethroplasty was done by continuous inverting subcuticular sutures with 6-0 PDS over 8Fr infant feeding tube. Second layer closed over the urethroplasty with local tissues with 6-0 PDS interrupted sutures. Right dartos flap was raised and sutured over the urethroplasty with 6-0 PDS. Glansplasty was done with 5-0 vicryl. Unhealthy skin was excised; edges were freshened and closed in 2 layers with 6 0 PDS and 6-0 vicryl rapide.

Picture 3: Complete degloving done and chordee assessed by artificial erection test. No chordee noted.

Picture 4: Urethroplasty done with 6-0 PDS, followed by glansplasty and skin closure

Picture 5: Appearance and urine stream at 2 weeks after catheter removal

Picture 6: Follow up at 6 months after surgery

Click here to watch the entire video of this surgery
Redo urethroplasty for a distal urethral fistula – Hypospadias Foundation, India

Redo urethroplasty for failed hypospadias

Redo urethroplasty for failed hypospadias is a highly complex and challenging surgical procedure. The primary goal is to address the complications of the initial surgery which are often associated with tissue scarring, shortage of tissues and presence of residual chordee. The general goals for any redo urethroplasty are to straighten the penis (correct any residual chordee), to reconstruct the urethra (create
a new wide and patent urinary passage) and place the urinary opening at the tip of the penis (glanular meatus).

Redo hypospadias repair should be performed by a experienced pediatric urologist or hypospadias surgeon who has expertise in complex hypospadias repairs. Surgeon should wait atleast 6 months after the initial repair to allow the inflammation to subside and for the scar tissue to soften. Sometimes if there is significant scarring, we wait for even 1-2 years and use steroid creams to soften the scar area.

About Hypospadias Foundation

Hypospadias Foundation is a centre specialized for treatment of children with hypospadias. It is located at MITR hospital, Kharghar, Navi Mumbai in the state of Maharashtra, India. Our expertise in primary and redo hypospadias repair makes us one of the best centres for hypospadias treatment in the world. We get children from more than 30 countries in the world with various types of complications after hypospadias surgery done at other centres and we are able to repair them successfully with good cosmetic outcomes. This is possible because of our dedication in the field of hypospadias.

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.

Single stage hypospadias repair in a child with recurrent distal penile fistula

A urethral fistula after hypospadias repair is an abnormal communication that forms between the newly reconstructed urethra and the skin on the underside of the penis. This is the most common complication that occurs after hypospadias surgery. In this condition, the urine comes from the tip of the penis and leaks from the fistula site.

This fistula mostly occurs due to issues with healing of the urethra. The common reasons include tension on the newly reconstructed urethra, poor blood supply at the operated site, gaps during closure, infection at the operated site, narrowing or stricture formation in the new urethra or straining while passing stool in the post operative period.

Children who form fistula after hypospadias surgery come with leaking or dribbling of urine from the fistula site. Symptoms usually appear within a few weeks to months after the initial hypospadias repair.

The primary treatment is surgical repair if they do not close on their own. It is standard practice to wait for atleast 6 months after the initial hypospadias repair before attempting fistula closure. This allows the tissues at the urethral fistula site to soften, improve blood supply and increase the success rate of second surgery. The fistula tract is identified and excised to create healthy tissue edges for repair.

The urethral fistula site is closed in multiple layers as done in the above-mentioned case to ensure a watertight seal and prevent recurrence. Before closing the fistula, it is always necessary to confirm that the urethra beyond the fistula site is not narrow or tight. In the presence of distal obstruction, the urethral fistula closure surgery may fail.

If your child has developed urethral fistula after hypospadias repair, then it’s necessary that you see a hypospadias specialist who will assess what is best for your child and choose the best technique minimizing the risk of complications and improving the chances of success.

About Hypospadias Foundation

Hypospadias Foundation is a centre specialized for treatment of children with hypospadias. Hypospadias foundation is located at MITR Hospital in Kharghar, Navi Mumbai in the state of Maharashtra. 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.

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Failed hypospadias with urethral stricture and fistula – Two stage oral mucosa graft urethroplasty

Second stage repair (Urethroplasty)

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