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

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

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

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

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

Second stage hypospadias repair:

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

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

Stage 1 Repair- Chordee correction and Oral Mucosa graft

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

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

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

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

Stage 2 Oral Mucosa Graft Urethroplasty

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

Distal penile hypospadias repair surgery in an adult

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

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

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

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

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