Hypospadias is a common congenital condition in boys where the urinary opening (urethral opening) is located on the underside of the penis instead of the tip. Hypospadias surgery is usually performed in early childhood, ideally before the age of five.

After successful hypospadias repair, the penis appears similar to a circumcised penis with urinary opening on tip and no curvature. The child will be able to pass urine in a single straight stream from the tip of the penis without pain or difficulty.

Because the surgery is performed very early in life, many children do not remember the condition or the procedure. As a result, many parents wonder:

Should we tell our child about his hypospadias surgery?

The answer is yes—open communication is important for your child’s long-term emotional and medical well-being.

Why parents have difficulty in talking to their son about hypospadias?

Many parents struggle with discussing hypospadias with their child due to social and emotional concerns such as

1. Cultural Taboo Around Genital Health

In many families, conversations about genitals or sexual health are considered uncomfortable or inappropriate. Parents who grew up in such environments may find it difficult to discuss these topics openly.

2. Fear of disclosure leading to social judgement and stigma

Parents often hesitate to disclose such conditions to their child due to fear that the child might share it with others, leading to social judgment. They may worry about teasing, stigma, or misunderstandings from peers, relatives, or the wider community. Concerns about how
the information could affect the child’s social relationships, self-esteem, and even future aspects like marriage or fertility can make parents cautious. As a result, some choose to delay or limit discussions, hoping to protect the child from potential negative reactions.

3. Concern About the Child’s Emotional Reaction

Some parents fear that their child may feel embarrassed, feel different from others, or become emotionally distressed if he learns about his hypospadias condition. Although these concerns are understandable, keeping the condition completely hidden may lead to problems later in life.

Why It Is Important to Tell Your Child About Hypospadias

1. Prevents Trust Issues

Children may eventually discover their medical history through records, online searches, or medical consultations. Learning about hypospadias surgery later in life from another source may make them feel betrayed or confused. Hence open communication is necessary to build trust and prevent unnecessary anxiety.

2. Reduces Body Image Concerns

As boys grow into adolescence, they naturally become more aware of their bodies. If they notice that their penis looks slightly different without understanding the reason, it may lead to unnecessary insecurity.

3. Prevents Anxiety During Puberty

Puberty brings many physical and emotional changes. Understanding their medical history helps adolescents feel confident and reduces anxiety about their bodies.

4. Helps With Healthy Relationships in Adulthood

Men who are unaware of their hypospadias repair history may feel worried or embarrassed about their appearance during intimate relationships. Knowing the truth early helps build confidence and reduces fear of judgment.

5. Seek help if they have medical issues

While with current hypospadias surgery techniques, the long-term results are very good, some of the children may develop issues in adulthood related to hypospadias or surgery done in childhood. These issues may include stricture, diverticulum, recurrent chordee or rarely urinary infections. Hence, it is important that the parents handover the medical records and tell their child about surgery so that they can seek proper help should anything happen.

6. Future urological interventions

Even in men without prior hypospadias, some of them develop kidney stones or prostate issues in late adulthood. At time of intervention, there is often cystoscopy done via urethra. Hence, it is important for them to know that they have a reconstructed urethra and share the same surgery record with their treating adult urologist.

What Is the Right Age to Talk About Hypospadias?

The best time to discuss about hypospadias with your child is during adolescence. At this stage, teenagers are mature enough to understand medical information and can process the explain logically.

Parents can explain that:
 He was born with a small difference in the position of the urinary opening.
 A hypospadias surgery was performed in childhood to correct it.

The condition has been successfully treated. It will not affect his normal life, urination, or future relationships. Having this conversation in a calm and supportive manner helps the child feel reassured and informed.

Why Medical Records of Hypospadias Surgery Are Important

When your child becomes an adult, it is important to provide him with all documents related to his hypospadias repair surgery. These records can help doctors if he ever needs medical evaluation later in life. Although most boys who undergo hypospadias surgery in childhood live completely normal lives, some rare complications can occur in adulthood, including:

1. Urethral Stricture: The reconstructed urethra may become narrow over time, affecting urine flow.
2. Urethral Diverticulum: The reconstructed urethra may become slightly dilated or relaxed.
3. Residual Chordee: A mild curvature of the penis that was not fully corrected in childhood may become more noticeable in adulthood.

Having the surgical history and medical records helps doctors provide appropriate treatment if any issue arises.

Who Should Explain about Hypospadias to the Child?

The best approach is for parents to have the conversation along with the hypospadias surgeon.

Together, they can reassure the child that:
 The condition was corrected successfully.
 He can lead a completely normal life.
 If he has questions or concerns, he can discuss them privately with the doctor.

We also recommend a follow-up consultation around 18 years of age so that the young adult fully understands his medical history and can address any concerns.

Final Thoughts

Talking to your child about hypospadias and hypospadias surgery may feel uncomfortable at first, but open and honest communication is important. When parents discuss the condition At the right age, it helps build trust, confidence, and a healthy body image. Providing accurate information ensures that your child grows into adulthood feeling reassured, informed, and comfortable with his medical history.

About hypospadias foundation

Hypospadias Foundation, located at MITR Hospital in Kharghar, Navi Mumbai in the state of Maharashtra, India is a centre specialized for the treatment of children and adults 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 30 countries in the world and from all over India. Our dedication in this field has helped us achieve excellent outcomes.

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 a 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.

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

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

Risk factors for recurrent chordee:

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

Symptoms of recurrent chordee:

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

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

Treatment for recurrent chordee:

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

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

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

Pre degloving and post degloving chordee assessment

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

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

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

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

Urethral plate division and proximal urethral mobilization

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

Three ventral corporotomies

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

Dermal graft

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

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

Adults with recurrent chordee after previous surgery

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

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

About Hypospadias Foundation India:

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

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

Contacting the Hypospadias Foundation:

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

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

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

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

Understanding Hypospadias:

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

Hypospadias and Fertility: the Possible Connections:

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

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

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

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

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

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

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

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.

Dr A.K.Singal, Pediatric Urologist India

Well coming back to the point- One of the most common complications of hypospadias surgery is Urethral Fistula formation. Having a complication such as fistula is not the end of the road. If the family has faith and the surgeon is experienced, urethral fistula can be managed easily with a minor second surgery in most of the cases.

I wish to share one story sent by the parents on an email to us and without any changes. The family came to us from Pune to Navi Mumbai for hypospadias treatment. Here we go:

It was indeed the happiest day of our lives when we welcomed our little bundle of joy; but soon after our son was born, the paediatrician informed us the baby is having a condition called Hypospadias with chordee albeit the degree of both the conditions was really minor, yet requiring surgery. The term Hypospadias was unheard of until then by us as well as seniors in the family. It was so devastating for us to know that the little one is already scheduled for the surgery – especially on such delicate place – before even he is a month old. Although the surgery was never life threatening and was elective in nature, as parents we were extremely nervous and anxious. Like every anxious parent, we too googled about the condition – which helped us understand better about hypospadias – before taking the next step of seeing the surgeon. Here in Pune, we did meet at least 2-3 paediatric surgeons (not the urologists or who specialise in hypospadias surgery). A senior doctor suggested 2 surgeries even for this minor hypospadias. Later we met 2-3 more doctors who suggested various methods be it keeping baby hospitalised for 7 to 10 days with medicines administered through IV lines or keeping the baby open after catheterization plus keeping his legs tied to each other in order to avoid dislodgement of catheter when he moves his legs; not to mention we were extremely petrified after meeting all these doctors as they were not at all empathetic not cordial. Not unexpectedly we were not convinced with any of the doctors as through google we already had understood that the condition can be treated as a day care surgery and babies are managed on oral medicines and in double diapers. Here, no doctor was talking about diaper and taking the baby home next day if not the same day. With due to respect to these doctors, we didn’t want to go ahead with the doctor with whom we were not comfortable with whatever little knowledge we have had gathered on this subject. The question of finding the right doctor was still there. Again, while googling we could get to know that there could be doctors who specialise as paediatric urologists and have vast experience of treating the babies / kids with hypospadias. Thanks to google and age of internet we found Dr. A.K. Singal.

The day we met Dr. Singal:

By the time we met Dr. Singal, our son was already 5 months old. After meeting Dr. Singal we realised why things didn’t move ahead with the previous doctors. Meeting Dr. Singal was so up to the mark as he explained the condition in detail, what he will be doing in the operation theatre and how the baby will be managed post-surgery. He was not only empathetic but also cordial and could understand what exactly the parents must be going through when their little ones must go through the surgery at very young age. His attitude was very positive. We had met the doctor we were looking for. Needless to say, we were so convinced and decided to go ahead with the surgery by Dr. AK Singal. He confirmed that both the defects would be covered in one surgery and the chances of any complications could be considered up to 2-3%. The age he suggested for the surgery was between 6 to 9 months. We took our own time to decide on the date of surgery and scheduled it when he was 14 months old. In the meanwhile, we met Dr. Singal twice with the doubts that we had. Each time he was very cordial in explaining the doubts in detail.

On the day of Surgery:

It was finally the day of the surgery. Nevertheless, we knew that the surgery is going to be for baby’s own good, yet our hearts were in the mouth. The doctor, as well the staff are so good that they would cater to every alarm by an extra-anxious and sensitive parent like me. The surgery went well, and the baby was brought back to the room. He was sleeping most of the day but when he opened his eyes I missed my heartbeat in the anticipation that he, now, would feel pain and the soreness; but to our surprise, he did not have any post-surgical pain on that day and any following day thereafter till the wound was healing. He was at his playful best by the next morning of surgery. He was kept in double diapers i.e. a hole was made in the inner diaper through which catheter was brought out and left to drain in the outer diaper. This method provides a cushion to the operated site, avoids catheter getting pulled accidently and makes it easy for parents to carry the child. Doctor suggested us to go home the next day, but we decided to continue for one more day for the betterment of the child. The nurses were so attentive and very cordial. After removal of the dressing and catheter, unfortunately our son caught the infection at the operated site which resulted in an extremely tiny fistula, which could not be spotted unless seen with the extreme care. This fistula was so tiny that the urine would come out from it in a drop or two. Later, as he was growing the urine output from the fistula grew to multiple drops.

Next appointments with the doctor:

Despite our son developed the fistula, our faith in the doctor never faded away as we were sure that doctor must have done his job with 100% care, and it was our and our baby’s fate to have the complication. The doctor never rushed and pushed us for the second surgery. He was hopeful that this tiny fistula can be healed on its own over the course of time; but the misfortune may have it, the fistula never healed, and worsened with the age by the end of year 2018. We had no choice but to put him through yet another surgery. This time as well the same protocols were followed and now our son is doing good after relatively minor second surgery.

Notes for the parents:

• Please do your research when your little one requires any kind of surgery.
• Have your questions ready so that you don’t miss any of them while you see the doctor
• Trust your vibes. Don’t go ahead with the doctor unless you’re 100% convinced.
• Get all your doubts cleared before you schedule your little one for the surgery
• Take a note of your baby’s food habits and arrange for them well in advance, especially if you are an intercity / interstate / international patient. Carry sufficient (or maybe surplus) supplies during this crucial time as the baby / child can be cranky due to change in schedule and nonetheless due to procedure.
• Carry his / her favourite toys, as that can sooth them.
• Engage them with cartoon videos
• Most importantly, however low and stressed you feel, never show baby /child your emotions and keep the spirit high. This is a tough time which too shall pass, just hang in there.
• Follow medicine schedule very promptly. Be on top of the pain. Be very punctual when to comes to medicine schedule.
• Be vigilant but don’t panic, call the hospital if you are not sure what to do?

Hope this story helped the families out there in some way. The lessons from the story can help both the surgeon and the family in having faith in the worst of times.

Take care and god bless.

Dr Singal

Like every other surgery, hypospadias correction surgery has its own risks, complications and failures. Inspite of the best intentions and efforts of the parents and the treating hypospadias surgeon, still the results may be sub-optimal after the first surgery. Though at the end of hypospadias surgery in OT it may seem that the surgery has gone very well, sometimes there may be minor complications which necessitate a second surgery for hypospadias in some children. The rate of second surgery for a complication or failure of first hypospadias surgery decrease with the expertise and experience of the hypospadias surgeon but it is never zero and that is an important thing for the parents and families to understand.

When the first surgery for hypospadias fails, parents get very disturbed and start looking for more information on why it happened and the solutions and second opinion for hypospadias to help fix the problem. Most of the times, the primary surgeon may be the best person to solve the problem but sometimes the complication may be severe and in such cases the patient should be referred to a centre of excellence in hypospadias surgery.

While minor problems like fistula or cosmetic issues can be treated easily with as second minor surgery- major complications of hypospadias surgery such as urethral breakdown, dehiscence, urethral diverticulum or stricture may require more complicated or even a staged repair with grafts. Hence, the dictum- that first surgery for hypospadias is the best surgery- further surgery if the first one fails is always more difficult and challenging.

At Hypospadias Foundation, we regularly receive kids and adults from all over India and other countries who have had a failed hypospadias surgery elsewhere. Families request for a second opinion for the hypospadias treatment and we advise them comprehensively. Some of these cases really benefit from the specialist care offered by a dedicated hypospadias team.

Case Story

Master A.G., a 3 years old boy, resident of Nagpur, underwent a surgery for a proximal penile hypospadias surgery at a hospital in Vellore. Unfortunately, the healing was not optimal and the whole repair had a breakdown. After 6 months of previous surgery, the family wrote to us and visited us at our centre in Kharghar, Navi Mumbai. On examination, the child has proximal penile meatus with mild chordee. There was a remnant of foreskin (prepuce) on the underside of penis. There was no foreskin left on the topside of penis. We explained to the parents that this may require a two stage repair but we will try out best to make a flap from the residual foreskin and do the surgery in one stage.

Finally after pre-surgery tests and fitness assessments, we took the child for redo-hypospadias surgery. We could make a nice onlay flap out of the foreskin remnant by carefully dissecting the blood supply and preserving the supply to this flap skin. The flap was used to make the new urethra in one stage as it can be seen in the video below.  The surgery took about 3 hours and the child was allowed feeds four hours after surgery. The dressing was removed after 7 days and catheter after 10 days. The hypospadias site healed very well and the child was examined again after 1 month. He was passing urine well in a single stream from the tip of penis. Now, 6 months after hypospadias repair, A.G. continues to do well and his parents are very happy and we are also overjoyed to achieve a good result in this challenging failed hypospadias case. The detailed hypospadias surgery video can be watched by clicking below. Besides the story mentioned here, the video below shows another child story from Raipur, Chattisgarh where the first surgery resulted in a penile torsion and a large fistula. The child underwent a successful single stage surgery at Hypospadias Foundation:

Watch Video of Failed Hypospadias surgery by Dr A.K.Singal

Hypospadias remains the most common urological abnormality affecting more than 1 lakh kids in India alone (based on incidence of 1/150 in newborn boys). Leaving aside very minor hypospadias without chordee- almost 70-80% of these require hypospadias treatment in form of repair surgery in early childhood.

For a child with Hypospadias, the first surgery is always the best surgery but still there can be complications and failure even in expert hands though complications are much less if operated by a surgeon or a centre where there is a focused practice in treating children with hypospadias. Literature and experts suggest that if a hypospadias surgeon is doing more than 50 hypospadias repairs in a year, then his results will be better and more predictable as compared to a general pediatric surgeon or a urologist who does only 10-20 hypospadias repairs in a year. Once a hypospadias surgery fails, then the next surgeries become more difficult and result more unpredictable. The failure rate of hypospadias surgeries vary from 5% to 50% depending on the type and severity of hypospadias in general centres and less than 10% in centres where hypospadias surgeries are done by expert hypospadias surgeons on a day to day basis.

Case details

Master A.P. was born with a distal penile hypospadias and underwent first surgery in Ahmedabad at the age of 6 years. Unfortunately, the surgery failed and he started passing urine from the same place on the underside of penis- a fistula. The new urinary passage through the head of the penis got tight and closed off. The surgeon tried to open it many times by catheter insertion but it failed. Coupled with failed hypospadias, the child also had an unsatisfactory cosmetic appearance in form of bunching of skin on underside of penis. With this situation they contacted Dr A.K.Singal, Pediatric urologist and expert Hypospadias surgeon at Hypospadias foundation in Kharghar, Navi Mumbai when the boy was ten years of age. After examining and confirming that the whole urinary pipe will have to be remade from distal penile region to the tip of penis (glans), Dr Singal advised a Onlay island flap repair for which the flap would be raised from the nearby bunched up skin. This repair is technically challenging because of previous failed hypospadias surgery but this was the only chance for the boy to have a single stage repair. The surgery for failed hypospadias was finished in 2 hours and A.P. was ready for discharge the next day but since they had travelled all the way from Gujarat, they decided to stay for 7-8 days in Navi Mumbai. The catheter was removed on day7 and he passed urine well from the tip. For the first one month after surgery, there were some chances of new opening getting tight, hence we taught the boy to insert a small catheter just 1cm into the new opening with an antibiotic ointment. The penis healed well in next 3 months and he has remained free of all symptoms now for last 5 years. At 15 years of age and after his 10^th standard exams, A.P visited us and had a big smile on his face. He is looking forward to higher education and he shared with us his dreams and further education goals. We plan to see him again one last time at 18 years of age. His penis growth and his functional & cosmetic outcome has been excellent so far.

Besides 100,000 kids born in India every year with hypospadias, there are an estimated 5-10 lakh adults living with either unoperated hypospadias or failed hypospadias having complications of Hypospadias surgery. These can be minor issues such as urethral fistula, chordee or suboptimal cosmetic results but a significant number may have major issues such as completely failed hypospadias, urethral diverticulum, hairy urethra, urethra stricture etc. Unable to come to terms with penile deformity, they do not get any hope or assurances from adult urologists or plastic surgeons as this may not be the area of primary interest or dedication for them.

Mr Rajveer Singh, 30 years old man, had a midpenile hypospadias with chordee and was operated by a plastic surgeon in Hissar Haryana 2 years back. After surgery, there was a breakdown of hypospadias repair and he was still passing urine from underside of penis. He was still having a downward curvature of penis (chordee) even after this surgery. Also he had seen hair growing out of urinary opening over last few months. He was very worried as he wanted to get married, hence he wrote to us asking for help. We wrote back asking for detailed pictures on email which would help us in understanding his clinical condition and hypospadias deformity. Finally, we called him to see us at Hypospadias Foundation in Kharghar, Navi Mumbai. He took a flight from Delhi to Mumbai and landed up in my Hypospadias clinic on a Monday evening. On examination, he had a urinary opening much below the head of penis in midpenile region and also a couple of holes (urethral fistula) from where he was leaking urine. More importantly his penis still looked bent due to uncorrected chordee. Lastly the cosmetic outcome was really bad with tags of skin here and there and we could see hair coming out of his urethra due to previous failed improper hypospadias surgery. This results when an undertrained hypospadias surgeon uses hairy penile skin for urethral reconstruction. We counselled Rajveer regarding the surgical plan the first step of which would be excision of all unhealthy skin tissue on underside of penis, chordee correction (straightening of penis) and then decide for the type of hypospadias repair in operation theatre. This would be either a single stage repair using a local flap from hairless penile skin or a staged repair using a buccal mucosa graft. In staged buccal mucosa graft – we first excise all unhealthy tissue and scars of failed hypospadias repair, then take a thin lining from inside of lower lip or cheek and then place it as a graft on underside of penis. Once this graft gains local blood supply from penis tissue, we roll it into a urethral tube typically after 6 months of first stage. We always keep buccal graft as the last option in failed hypospadias as that essentially means multiple surgeries. Hence, we attempt to do a single stage flap repair whenever feasible even in failed hypospadias and hence we shared this intent with Rajveer.

Rajveer was taken up for surgery the next day under spinal anesthesia and first a cystoscopy was done. It showed normal urethra beyond midpenile region and unhealthy scarred hairy urethra with fistulae in the distal penile region. We excised all the unhealthy tissues and then checked for chordee. There was still 30 degrees bend in penis which needed correction by a 12 O’clock non-absorbable stitch on the top side of penis. On rechecking with artificial erection, there was no chordee now. After chordee repair was satisfactory, we analysed the penile skin on the right side of penis. We could see an island of hairless skin which was possibly remnant of foreskin (prepuce). We designed a long flap from this with very good blood supply from the underlying dartos tissue. This flap was used in an onlay fashion to repair hypospadias in a single stage. Finally head of the penis (glans) was also repaired and a catheter was placed to drain urine till the whole repair healed. Rajveer went back to his home town in Haryana after 3 days of surgery and then we arranged for one of my surgeon colleagues in Hissar (Dr Vivek Gupta) to help with post hypospadias surgery care. The catheter was removed on day 14 since it was a major hypospadias reconstruction. Rajveer passed urine well and but the full healing of the penis took about 4 weeks. The final cosmetic result was excellent when he sent the pictures via email. He visited us recently almost 3 months after surgery, the penis looked well healed and he is passing urine well from the tip in a good stream. His erections are straight and he is now looking forward to get married. The only question is whether he will invite me for his wedding or not and if he invites, how will he introduce me.

When such complex failed cases do well after hypospadias treatment at Hypospadias foundation, it makes us very happy. We feel our goal of starting the foundation in Nov 2008 has been fulfilled. Last six years have been a long and exciting journey but is has been a very challenging time. When we started we never knew the burden of problem was so high.  Along the way we have been privileged to be a part of lives of more than 600 kids and adults with Hypospadias from all over India and some countries abroad. Almost 25% of those receiving treatment at Hypospadias Foundation, have been patients with failed hypospadias who received surgery elsewhere. Though initially we started only with management of hypospadias in children but we realized that there is huge gap when it comes to treatment of hypospadias in adults. Along with Dr Manish Dubey, my close friend who is an adult urologist we are able to offer good care and success rates in adults and failed hypospadias.

In last three years, Hypospadias Foundation has welcomed many patients from many other states and countries such as Nepal, Bangladesh, Greece, Afghanistan, Iraq, Saudi Arabia, UAE-Dubai, Oman, Great Britain (UK), USA, Nigeria, Tanzania, Kenya, Congo, Zambia and this number continues to grow attesting to our devotion to the field of Hypospadias. Within India, kids and their families have travelled for treatment of hypospadias from Assam, Kolkata, Orissa (Puri, Bhubhaneshwar), Ranchi, Chattisgarh (Raipur, Katni),  Gujarat (Ahmedabad, Surat, Baroda, Gandhinagar), MP (Indore, Bhopal), Himachal, Delhi, Haryana (Hissar, Rohtak, Panipat), Rajasthan (Bikaner, Jaipur, Jodhpur), Maharashtra (Jalgaon, Pune,  Aurangabad, Nasik, Nagpur, Parbhani, Dhule, Solapur, Kolhapur, Ahmednagar, Ratnagiri), Uttar Pradesh (Lucknow, Allahabad, Meerut), Goa, Andhra Pradesh (Hyderabad, Belgaum, Guntur), Uttarakhans (Dehradun), Jammu, Kerala (Cochin), Tamilnadu (Chennai, Salem, Coimbatore) and Punjab (Chandigarh, Ludhiana and Patiala).

About the author:

Dr A.K.Singal is a Pediatric Urologist and Hypospadiologist practicing in western india in area of Navi Mumbai and Thane. He is counted as one of the best hypospadias expert surgeons in the world and every year manages more than 200 kids and adults with hypospadias. He is available at the following clinics :

Watch video of Distal penile hypospadias repair surgery by Dr A.K.Singal