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April 04 2014

Letter from Across the seas : Mother of twins shares Hypospadias Surgery guide for parents

Author Dr. A.K.Singal Categories For Parents and Patients

Letter from Across the Seas:

Dear Dr Singal,

Trust all is well with you. We are glad that we came all the way to India to you for our boys and are thankful to you for treating our boys with such care and in a single stage surgery for Hypospadias. As discussed, I have written the write up for the blog. These are basically my views, learnings and tips for other parents, especially the Hospitalization including pre-surgery and post hypospadias surgery course.

Regards,

S.P.

Dubai

THE WRITE-UP

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Dear Parent,

As parents we all are concerned for our child(ren)’s wellbeing. We interact a lot with Pediatricians and Specialist Pediatrician from birth till their teens. From Vaccinations to Major surgery we ensure our child(ren) gets best of the treatment and care. Until both my twin boys were detected with Hypospadias, I was inexperienced and the entire journey from initial diagnose to surgery has taught me a lot.

Here are some tips, learnings and guidance for parents

Before the meeting the Doctor

1.    Most cases of Hypospadias are detected at birth. The Pediatrician at birth may not be expert enough to guide further so it’s better to consult a Pediatric Urologist or expert hypospadias surgeon as soon as possible.

2.    There is no benchmark for earlier consultation, but its better the visit to the Pediatric Urologist when the child is less than 6 months old.

3.    If you are an outstation patient and are communicating with the doctor over emails ensure you share following info:

  • Baby’s Allergies and medications
  • Any special medication or condition
  • Any hospitalization and the reason

Sometimes this information doesn’t affect the course of hypospadias surgery but its always safe to share as this helps the anesthesiologist for planning a safe anesthesia

4.    If you have a limited timeframe for your visit than

  • Check if there are any further tests (like blood or urine tests) or investigations required before you meet the pediatric urologist
  • As required by the doctor, perform the tests and send the reports to doctor for further guidance. This can be done via email. Since I was traveling from Dubai, I did these tests as recommended by Dr Singal even before I landed up in Mumbai
  • Sometimes a certain blood count such a hemoglobin may be needed to be normal before hypospadias repair procedure is required to perform before surgery and if the count is not as preferred it may take month to reach the desired level.

5.    Check for the travel plans of the doctor so that it doesn’t clash with your visit. Sometimes the doctor maybe traveling for vacation or for a conference.

6.    Convey your travel plans to the doctor

Once you meet the doctor, most of your doubts will be cleared in the initial meeting. A date for hypospadias surgery will be decided in the meeting. If you have questions or doubts regarding the hypospadias treatment procedure please ask the doctor, he will be happy to guide. Sometimes you may have doubts or questions post consultation check with the doctor if you can email for such doubts. The doctor may suggest hospitalization before the day of the surgery and also some additional tests whenever needed.

My twin son’s both had hypospadias and we elected to have surgery for first kid on Monday and second one on Tuesday.

When we reached the hospital we had some minor issues as it was Sunday and we were supposed to see the doctor on call in ER. Since they were already alerted for our visit the doctor on call was prepared with all the requirements. They were to do a blood test on one of my twin. To avoid double prick they decided to insert cannula for one of my boys. And then the hell broke. We had two crying babies (one due to prick and other seeing the first one) and there were hospital formalities to be fulfilled.

Hospitalization

1.    Before admission to the hospital

  • Reach hospital half an hour before the schedule time.
  • Insist – The Cannula And Blood Tests Be Done Only After The Kid Is Settled In The Room
  • Request for the allotment of room and fulfill all the formalities
  • Ask for hospital clothes for the baby
  • Change the baby in hospital clothes
  • Once the child is settled than ask doctor on call to the needful

2.    Inform the hospital staff if your child is on a special diet and if they can provide.

3.    Carry baby products – wipes, diapers, any special food or milk powder you may be giving, soft toys which soothes them

4.    Carry you basic requirements for two days of hospitalization

5.    Since the hypospadias operation will be done under anesthesia, check till when the child be given food/water/milk.

 After Care

1.    Learn to change the baby double diaper. We were happy as with double diaper technique the babies were nicely tugged in and there was little fear of catheter dislodgement.

2.    Learn the medications of the baby

3.    Don’t discontinue medication unless the doctor advise

4.    Follow up visits with the doctor

The child will have discomfort and can be cranky due to operation the doctor will guide you. This is a normal phase after any surgery with children as penis is a sensitive organ and pain may be there for a first few days. But as one learned person said “ This too shall pass” It did pass for us. Now when we look back, the difficult days just went by in a jiffy. With the love and support of Dr A.K.Singal, junior doctors and nurses, we saw them through.

My personal advice – Stay Calm and positive through the process.

All the best

Regards,

An experienced Parent

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Please feel free to write to us for an opinion at hypospadiasfoundationindia@gmail.com or fill this contact form http://hypospadiasfoundation.com/contact-patient.htm

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    February 02 2014

    Cost of Hypospadias Surgery in India

    Author Dr. A.K.Singal Categories About Hypospadias

    Hypospadias is a very common birth defect affecting up to 1/150 newborn baby boys. In the current era most of the couples choose to have one or maximum two children and that too with a lot of planning. The moment the newborn baby boy is diagnosed to have hypospadias – besides distress and worry for the baby’s health and future parents also start worrying about other things. These are:

    • When should the surgery be done
    • Where and by whom should the surgery be done
    • What will be the long term outcome after surgery
    • How much is the hypospadias repair surgery going to cost

    While the first three questions have been answered elsewhere, the last question forms the substance of this blog. Parents always worry ” Is hypospadias repair surgery going to be very expensive?, Would my insurance policy pay for hypospadias surgery since hypospadias is a birth defect”

    The cost of hypospadias repair surgery varies according to the type & severity of the hypospadias, type of surgical technique, time taken by the hypospadias surgeon, assistant used or not and finally type of room taken- general ward or shared room or a single deluxe room.

    • Elaborating further – for a mild variety of hypospadias like glanular/ distal penile hypospadias with mild chordee, an expert hypospadias surgeon will take under one hour for surgery, work without assistant surgeon and the charges may start from 1000 US Dollars (60,000 Indian rupees) while for a severe hypospadias such as scrotal/ perineal hypospadias the charges may go upto 3500 US dollars (2,00,000 Indian rupees) for a single stage urethroplasty.
    • Some of the hospitals in Mumbai may be more expensive than say for example Hypospadias Foundation at MITR Hospital in Navi Mumbai.
    • For some of the severe hypospadias a staged urethroplasty repair may be needed and then the budget may extend further but this happens in less than 5% of the cases. Though at Hypospadias Foundation located at MITR Hospital in Kharghar, Navi Mumbai, majority of our hypospadias repair surgeries are single stage urethroplasty surgeries, still in 4-5% of the children referred to us, the hypospadias may have a very severe chordee necessitating a two stage approach for better long term outcomes.

    Hence, the actual charges of hypospadias repair can only be decided after a full hypospadias examination and discussion with the parents face to face.

    Similar hypospadias surgery in USA carries upto ten times the charges and maybe 5-6 times of Indian charges in Europe. When looked at in context of India, though most of the families are able to afford these expenses, for some indian families these may still be high. Some of these families get support from Hypospadias Foundation either as medical consumables support or by way of some discounts in surgeries at Hypospadias Foundation. We have tried to ensure a policy of NEVER Saying NO to a child with hypospadias for economic reasons. If the intent is right, money comes in as Donations etc.

    Coverage of Hypospadias by Insurance Companies:

    Hypospadias being a birth defect is generally not covered by most of the insurance companies in India atleast while in USA, UK it is covered under insurance benefits. Some of the corporate insurance group covers do include all pre-existing as well as birth defects for their employees and hence hypospadias repair procedure may be covered by the insurance company by some of these companies.

    In the other cases, the parents usually end up paying up these charges by themselves out of their own pocket. For new parents working in a job or middle class environment this may be stressful. What helps is that Hypospadias repair surgery is a planned procedure. It can be done anytime between 6 months-15 months of age giving parents enough time to rally around and arrange everything from money to other resources. Hence, it is best that they meet a hypospadias expert or a pediatric urologist early on in first 1-2 months and then learn everything about the charges, hospital stay, pre-hypospadias surgery tests and then get mentally prepared for the actual surgery.

    Please feel write to us for an opinion at hypospadiasfoundationindia@gmail.com or fill this contact form Contact Hypospadias Foundation

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      February 02 2014

      Goals of Hypospadias Repair Surgery

      Author Dr. A.K.Singal Categories About Hypospadias

      Before we talk about goals of hypospadias surgery, let’s understand the issues in uncorrected hypospadias.

      Anatomical defects in Hypospadias: Hypospadias encompasses two basic structural defects in the penis- abnormal location of the urinary opening and chordee (bend in the penis). Another minor defect is incomplete foreskin (prepuce) which does not lead to much cosmetic or functional impairment. We regularly use prepuce and its internal tissues for performing a strong structural hypospadias repair, hence circumcision most often is a part of the procedure.

      Functional issues in Hypospadias: Functionally, penis has two important aspects:

      1. Ensure Smooth uninterrupted flow of urine-possible by a wide caliber of urethra
      2. Sexual organ for intercourse and also for passage of semen for fertility

      Except in minor hypospadias, in all moderate to severe hypospadias both these functions are impaired unless corrected.

      Cosmetic deformity in Hypospadias: Last but not the least, except for very minor hypospadias without chordee – all the other hypospadias lead to significant cosmetic deformity which most of the teenagers and adults would not accept as normal. Genital perception is important in overall normal development of the child into a balanced teenager and adult later on.

      Goals of Hypospadias repair: Hypospadias surgery procedure (urethroplasty) mostly in single stage and rarely in multiple stages (depending on the severity of hypospadias) aims to correct these structural defects, impart a good functional outcome both from urinary perspective all throughout life and later in adulthood for sexual purposes with a good cosmetic appearance.

      Hence, when doing the hypospadias correction, a hypospadias expert surgeon keeps all these goals in mind. The stepwise approach with a standardized protocol helps in achieving all these goals. Over the last two decades, lot of research and dedicated best hypospadias surgeons have made sure that the anatomy and functional aspects are taken care of in an appropriate manner with long lasting good outcomes.

      Stepwise standardized hypospadias surgery protocol

      (As practiced by Dr A.K.Singal, Pediatric Urologist & Hypospadias Expert)

      After nearly 7 years of dedicated hypospadias surgeries, we and other top hypospadias surgeons have realized that it is very important to follow a standardized approach as follows:

      • Examination under Anesthesia with magnification: The clinical examination done in outpatient department may not have been sufficient. Re-examining the child under anesthesia in detail while wearing magnifying loupes allows a hypospadias surgeon to create a mental roadmap. While scrubbing, draping, painting this roadmap provides a reliable navigation and focus to achieve best results during hypospadias repair.
      • Marking of skin incisions and injection of anesthetic agent with adrenaline: We routinely as a first step mark the incision sites and then inject dilute xylocaine and adrenaline and then wait for five minutes. This prevents minor bleeds from the hypospadias surgery site and keeps the area clean. This also allows decreases the use of electrocautery to stop the bleeding to a minimum.
      • Degloving the penis: Incisions are deepened preserving the nerve and blood supply to penis and whole skin of the penis is taken down – a step called degloving. This is done in all l hypospadias surgeries and most of the times is enough for correction of the chordee. The penis is carefullu delgoved preserving the urethral plate. Till this time, the technique of hypospadias repair is still not decided.
      • Chordee correction: Once penis is completely degloved, an artificial erection test is done to make sure that the penis is straight else various types of chordee correction procedures can be done. Straightening of the penis is the prerequisite for any type of urethroplasty and a surgeon should not move ahead with urethroplasty till chordee correction is satisfactory.
      • Deciding the technique of Hypospadias repair (Urethroplasty): After chordee correction, anatomy is assessed again. If the hypospadias is not very severe and the urethral plate (tissue between urinary opening till the glans) is wide, soft and elastic- a Tubularised Incised plate urethroplasty (Snodgrass repair) can be done). In a proximal hypospadias or a poor urethral plate, onlay island flap repair should be done. If the skin just below the urethral plate is good, then a Mathieu’s flip flap repair can also be done. If the urethral plate has been transected to correct the penis curvature then a precpucial tube repair should be considered or a staged hypospadias repair can be done.
      • Second layer coverage to prevent fistula: A second layer cover over the new urethra is very important to prevent urethral fistula post hypospadias surgery. This can be taken from surrounding spongiosum, dartos fascia from prepuce or tunica vaginalis (covering of the testis)
      • Glansplasty and meatoplasty: Reconstruction of the head of penis is a critical component for good cosmetic result as well as to make sure the opening is wide enough to allow free passage of urine. This is ensured by wide dissection of glans and also while closing the glans new urethra should be able to accommodate a good sized catheter without tension. Meatus should be left wide and an effort is made to make it like a slit like meatus which is cosmetically pleasing.
      • Penile skin closure: Excess prepuce on the top of penis is split in midline and brought on either side towards underside of penis. Jacket shaped incisions are made to remove extra foreskin and then a midline suture line is created for an excellent cosmetic outcome after hypospadias repair.
      • Proper fixation of the catheter: Urethral catheter is fixed with a stitch taken through glans so that it stays inside. The catheter is kept for 5-10 days depending on the type of surgery and healing.
      • Dressing: Decade ago very bulky and tight hypospadias dressings were in vogue, nowadays we use very soft and light dressings which can be removed easily an then let the catheter drain into a double diaper.

      Following these sequential hypospadias surgery steps and a standardised protocol over last few years in more than 500 kids, has led to faster surgery, shorter anesthesia times, lesser bleeding, better cosmesis and extremely low rates of complications after hypospadias surgery at Hypospadias Foundation. And most importantly, this has also made sure that all the goals of hypospadias surgery are properly met.

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        January 01 2014

        Living with Hypospadias- Adults with hypospadias

        Author Dr. A.K.Singal Categories Adult hypospadias

        The tale of hypospadias does not stop in first few years of life for everyone. This is especially true of adults and adolescents who underwent hypospadias surgery repair using older techniques and with lesser trained Hypospadias surgeons 15-20 years back. While a majority of these have done well, there is a sizable population of adults in India who have persistent issues secondary to hypospadias such as urethral fistulas, persistent penile chordee (bending of penis), urethral stricture or bad cosmetic outcome. As Pediatric urologist and a surgeon with deep interest in hypospadias (hypospadiologist), we keep seeing such patients on a regular basis now.

        There are atleast estimated 5 lakh adults/ adolescents in India with untreated, complicated or residual issues of hypospadias in India. Some of these people live an unsatisfied life thinking that no cure is possible because that is what they have been brought up to think. Individuals who have failed multiple surgeries are called Hypospadias cripples in medical community signifying the crippling effect which inadequately treated hypospadias can have in a person’s life.

        Fortunately, with newer techniques, better hypospadias surgery instruments, very good sutures like PDS, availability of dedicated hypospadias surgery teams and expert hypospadias surgeons good results are possible in any patient with previous failed hypospadias surgery even in hypospadias cripples.

        Here is story in point:

        Six months back I saw Mr RK, a 30 year old young man, who had been a case of failed hypospadias – operated for hypospadias twice in his childhood in a hospital in Delhi. Both the surgeries had met with partial success and his parents had left him like that and lost hope at a completely functional urethra. RK had been a good student and went on to do Engineering graduation from IIT and then a MBA from Pune. He had taken up a job in multinational company and now was planning to get married. Infact, he had delayed marriage inspite of a successful career because he was never satisfied with outcome of his hypospadias surgery. That’s why he looked up on internet and came to see us at Hypospadias Foundation in Navi Mumbai.

        At the first consultation itself and being in relatively the same age group, we hit it off really well and he was quite frank and objective about his condition and that kind of interaction helps a hypospadias specialist like me. When I examined him, he had a persistent mild chordee but the bigger issue was his urinary opening (meatus) was not on the tip of penis (glans penis) but way down in distal penile location. He had many skin bridges and scarred islands of skin and a large urethral fistula in proximal penile region. There was a bit of penoscrotal transposition as well. On questioning, he was passing 50% of the urine from the urethral fistula and 50% from the distal penile location without any straining and in good urinary stream. None of these problems were major by themselves and could have been cured easily but after two failed hypospadias repairs in childhood, I think parents just gave up hope.

        So we discussed with RK at length about the various things which needed to be done-

        • Distal urethroplasty using flap from nearby ventral penile skin,
        • Closure of urethral fistula (fistula repair) in multiple layers with tunica vaginalis flap
        • Correction of penoscrotal transposition
        • And chordee correction by dorsal plication.

        The surgery was done next week at MITR Hospital & Hypospadias Foundation. Dr Manish Dubey, Urologist and Co-founder of Hypospadias Foundation helped me with the surgery and management immediately post surgery. RK was sent home the day after surgery. A follow up visit for hypospadias dressing removal was planned on day 5 and catheter removal o day 10.

        Some of things especially in adults undergoing hypospadias surgery, which we took care of to ensure smooth recovery and are different from children:

        • Postoperative pain and erections
        • Choosing the right urethral catheter and drainage bag

        We were also worried about higher chances of wound infection and bleeding after redo-hypospadias repair. For pain and prevention of erections we gave benzodiazepine derivative tablets and phenobarbitone along with diclofenac and that helped pretty well for two weeks. For the catheter, we used a Foleys silicon catheter for 10 days and left it to drain in a urine bag which RK could carry with him and walk around within his home.

        Fortunately, everything went well and now after 3 months of hypospadias surgery, the hypospadias surgery site is healing well and there is no more pain during erections. The urine stream is good and RK is passing from the tip of his penis for the first time in his life standing like a normal man. He is not shy to use the public toilets anymore- He just stands up and delivers.

        We have asked him to wait for three more months before planning marriage and these three months he is actually going to spend in finding the right girl for himself. For him, we hope the chapter of HYPOSPADIAS is closed now.

        The only question remains whether as a Hypospadiologist I will get invited to his marriage- if yes, how will he introduce me? As the doctor who fixed his penis? I think that is too much and I will just skip attending his marriage and I wish him the best of luck always from our side and from everyone at MITR hospital and Hypospadias Foundation in Navi Mumbai, India.

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