complications of hypospadias Archives - Page 2 of 3

January 01 2024

Two stage oral mucosa graft repair in redo hypospadias

A 3 year 6 months male child presented to us in the OPD after two failed surgeries for hypospadias (done elsewhere). He had undergone a staged hypospadias repair at another centre in Mumbai and when he came to us, he had meatus at the proximal penile region probably due to complete dehiscence after stage 2 repair. The child was very apprehensive in the OPD because of a traumatic experience from previous surgery. On examination, the meatus was in the proximal penile region with very irregular unhealthy skin beyond that. At our centre, he was planned for cystoscopy, chordee assessment and most likely a staged oral mucosa graft hypospadias repair for best outcome.

On clinical examination, the meatus was at the proximal penile region with
unhealthy distal skin.

At the start of hypospadias surgery, chordee was assessed and there was no residual chordee noted. Deep degloving was done, all fibrotic tissues from the urethral bed were removed. Proximal urethra was mobilized. Chordee was reassessed and no chordee was noted. Skin was rearranged on the dorsal and ventral side. Raw area of 4x2cm was noted on the ventral aspect. Hence, we planned a stage 1 OMG repair i.e placement of oral mucosa graft.

Oral mucosa graft was harvested from the right cheek and placed on the ventral side from the glans till the meatus. Graft was quilted thoroughly on the corpora using 6-0 PDS.

Chordee was assessed, no residual chordee noted. Deep degloving done, all fibrotic tissues excised.

Skin rearranged on the dorsal and ventral side. 4cm raw area on the ventral side noted.

Oral mucosa graft harvested from the right cheek of size 4x2cm. Oral mucosa graft sutured on the ventral side from the glans till all around the meatus.

After stage 1, graft healing was good. Steroid massage was started 3 weeks after surgery and was continued for 5 months. Graft uptake was 100%. Second stage was planned after 6 months when the graft was soft and pliable. During the second stage hypospadias repair, chordee was reassessed and no chordee noted. Local anaesthesia – lignocaine with adrenaline was injected at the edges of the graft. Graft was incised at the margins and tubularized over a 7Fr Infant feeding tube (IFT). Second layer was closed using local tissues. Dartos flap was harvested from the left side and sutured over the urethroplasty using 6-0 PDS. Glans wings were widely mobilized and Glansplasty was done using 6-0 PDS. Glans epithelium was closed using 6-0 PDS. Skin was closed in 2 layers using 6-0 PDS and 6-0 vicryl rapide.

Graft was soft, 6 months after stage 1 repair. Chordee was assessed and no chordee was noted.

Graft was measured and 18mm width was used for urethroplasty. Graft was incised all around and tubularized and sutured using continuous inverting subcuticular sutures using 6-0 PDS.

Dartos flap sutured over the urethroplasty. Glansplasty and skin done hence completing Stage 2 OMG urethroplasty.

Dressing change was done after 7 days, and catheter was removed after 10 days. After catheter removal, the child passed urine in single straight stream with no pain or leak.

Post catheter removal, passing urine in single straight stream with no complications.

Two stage oral mucosa graft repair in redo hypospadias

Hypospadias is usually diagnosed after birth in the neonatal period by a pediatrician. Once diagnosed, referral to a pediatric urologist is necessary to plan surgery at the right age. As per the guidelines the best age for hypospadias surgery is between 9 to 18 months. Hypospadias Surgery is planned in single or two stages depending on the severity of hypospadias. After chordee correction, usually there is insufficient skin on the underside of the penis to reconstruct the urethra hence extra tissues either in the form of prepuce (in primary ones) and oral mucosa graft (in redo cases) are used for urethroplasty.

Prepucial skin can be mostly used only once for the hypospadias repair. If the first surgery is unsuccessful then we need to plan redo surgery by using skin from somewhere else due to lack of local prepucial skin. In these children, use of oral mucosa graft is an excellent option. The reason why oral mucosa can be used for urethral reconstruction is because it is hairless, thin and pliable similar to the natural lining of the urethra. Graft is harvested from the inside of the cheek or lip, fatty tissue from the graft is removed. The penis is prepared for placement of the graft and the graft is meticulously sutured on the corporal bed. The graft incorporates into the urethral bed and becomes soft in 6-8 months. Local Steroid massage is necessary to make the graft soft. Once it is as soft as lip it can be tubularized to form the neourethra. The beauty of oral graft is such that there is less risk of fistula formation, minimal donor site scarring and has good cosmetic outcomes. However, it requires specialized skill and experience to perform oral mucosa graft in hypospadias and there is a small percentage of adults or children who may develop graft rejection or failure. In these children or adults, we need to replace the graft completely by a new graft.

The above-mentioned case is of a boy who presented to us after two failed hypospadias surgeries in the past. The local prepucial skin was unhealthy, hence we opted for oral mucosa graft. The final cosmetic result in this boy was excellent and he was able to pass urine in single straight stream with no complications.

At Hypospadias Foundation in Navi Mumbai, after hypospadias repair including oral mucosa inlay graft urethroplasty, children are encouraged to walk, play, and do some activities at home comfortably. We do not advice bed rest. Tying the legs and restricting children from doing activities or walking is disturbing for the child. Encouraging them to do activities can act as a distraction and take their mind off from the discomfort and promote healing. With our vast experience in hypospadias, we would recommend that children be allowed to do some activities in the post operative period. Play can be powerful tool for children to express their emotions and process surgical fear.

About Hypospadias foundation

Hypospadias foundation is an organization dedicated for children and adults with hypospadias and is rated as the best hospital for hypospadias repair in India. It was founded in 2008 by Dr A K Singal and is located in Kharghar, Navi Mumbai. Hypospadias foundation offers best results for surgical repair for primary and failed hypospadias. We at hypospadias foundation believe in providing personalized care and psychosocial support to families of children and adults with hypospadias. The foundation also advocates improved access of care for people with hypospadias around the world.

Dr A K Singal is a well renowned hypospadias surgeon and regarded as the best hypospadias surgeon in India and in the world. His vision for hypospadias has helped him achieve excellent outcomes in adults and children with hypospadias. He has dedicated his life in treating children and adults with hypospadias with his innovative surgical techniques.

Dr Ashwitha Shenoy is an expert pediatric surgeon with special interest in pediatric urology and hypospadias. She holds a particular interest in hypospadias and along with Dr Singal performs advanced surgical techniques for both primary and complex hypospadias cases in children and adults.

Contact us:

For appointment kindly contact us at the contact details given below.

MITR hospital & Hypospadias Foundation, Kharghar, Navi Mumbai, India – Tue/Saturday 4:00pm-6:00pm, Call for appointments: +91-9324180553. Or email us at hypospadiasfoundationindia@gmail.com

or pls call up our clinic for an appointment – +91-9324180553

January 01 2024

Does Hypospadias cause male infertility?

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/

January 01 2020

Dr A.K.Singal presents his work at Hypospadias World Congress at Childrens Hospital of Philadelphia, USA

Hypospadias Foundation starts Clinic for Hypospadias Treatment & Surgery in Bahrain

Dr A.K.Singal was an invited speaker at Hypospadias World Congress at Children’s Research Center at Children’s Hospital of Philadelphia, USA, held between 30^th October 2019-1^st Nov 2019. Dr Singal presented four papers on hypospadias treatment and moderated scientific sessions during the conference.

The conference saw participation from more than 150 pediatric urologists and hypospadias specialists from across the world. The conference solely focussed on hypospadias. Various aspects of hypospadias were discussed such as etiology, diagnosis, hormonal tests and supplementation (testosterone injections), surgery techniques and complications/ results of hypospadias surgeries.

Dr A.K.Singal

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.

January 01 2020

A small complication in hypospadias surgery does not mean the end of the road: Surgeon and Family must work together

Hypospadias Foundation starts Clinic for Hypospadias Treatment & Surgery in Bahrain

Let me begin by saying: Hypospadias Repair surgery is not an easy surgery.

It takes a surgeon years to perfect the art and craft of hypospadias surgery. Every single slice of knife, every single snip of scissors, every single stitch holds the key to a successful hypospadias repair. Inspite of all this, sometimes the results of hypospadias surgery may be suboptimal. The reasons for this are many. Besides an undertrained surgeon or poor equipment or expertise, sometimes the healing after hypospadias surgery is unpredictable. Even after hypospadias surgery, the penis has erections every night, putting the repair at little bit of stress. There may be minor infection, or the child may be nutritionally deficient in micronutrients leading to poor healing. Even if these factors are controlled, individual healing is still very variable phenomenon, leading to a small rate of complications even in expert hands. In best hypospadias centres, hypospadias complications dip to less than 5% for distal hypospadias and less than 15% for severe hypospadias.

Any complication which happens can be disheartening for the family, the child as well as for the hypospadias surgeon. Surgeons particularly get emotionally disturbed and keep thinking about it even when they go back home and more so the surgeons who are sensitive. We as surgeons forget out 95% successes and keep carrying the burden of our complications back to our homes and our families, even the minor things haunt us. Though we may keep a strong face on the exterior, much required, inside we suffer every time something doesn’t go well. Hence, we keep striving for better and better results.

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

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Tag Archives: complications of hypospadias

Two stage oral mucosa graft repair in redo hypospadias

About Hypospadias foundation