hypospadias surgery Archives - Hypospadias Foundation

August 08 2014

Post-operative instructions and home care after hypospadias repair surgery

Hypospadias surgery is a delicate, skillful and complicated surgery. The good thing about hypospadias treatment is that young babies heal very fast and become well within a week to ten days after the hypospadias repair. Fortunately, unlike adults, the children do not think about pain. They live their life happily soaking in, everything moment to moment. Adults on the other hand think and anticipate pain too much hence they land up having more pain. It is the anticipation of the pain which is worse than the pain itself.

That being said, here we have tried to give detailed post hypospadias repair instructions for the parents and patients so that they can understand the care which needs to be taken after hypospadias surgery. Please note that these are generalized instructions after hypospadias surgery and there will be some variations on a case to case basis and it is best to discuss with your hypospadias surgeon for other details.

Diet: Children can often be fed 2-3 hours after hypospadias repair if the surgery was done under sedation and caudal epidural anesthesia. Some complex or failed hypospadias may require general anesthesia for surgery and these kids are kept empty stomach for 3-4 hours after surgery.
Urine passage: In almost all the hypospadias repairs, there is urinary pipe called catheter which is left across the hypospadias repair site. This goes into the bladder and drains drops of urine continuously. It is generally removed after 5-10 days by the hypospadias specialist depending on the type of the repair.
Diaper care: Post hypospadias treatment babies are kept in double diapers till the time the catheter is there. If the child is more than 6-7 years of age, then diapers may be difficult to maintain- hence we prefer to use a urine bag for drainage of urine. We ask the parents to make a hole on the front side of inner diaper and bring out the catheter to drain into the outer diaper. This way the inner diaper is changed only when the child passes motions and hence remains dry. Outside diaper is changed whenever it is full of urine.
Hypospadias Dressing care: At the end of hypospadias surgery, we place a soft gauze roll dressing on penis to give some support to the healing penis. There may be minor bleeding into the diaper on and off for first 3-4 days which is nothing to worry about. The hypospadias dressing sometimes becomes loose and comes out. If this happens within first 2-3 days, then we change the hypospadias dressing. If it happens later, we just remove the dressing and leave the wound open.
Discharge after hypospadias surgery: Most of the children who have a simple primary hypospadias are discharged the same day of surgery by evening- daycare hypospadias surgery. Children who are traveling from far may come the night before to hospital and stay for a day or two after surgery as well. Children who have undergone a failed hypospadias or a complex surgery are kept in hospital for 2 nights after surgery also for antibiotic injections or pain relief etc.
Pain relief: We prescribe an oral syrup of analgesic medicine mostly a combination of ibuprofen and paracetamol for first few days after surgery. This ideally should be given post feeds and not on empty stomach. We also give a medicine called oxybutynin which is an anticholinergic and prevents bladder spasms (painful bladder contractions due to catheter).
Medications: A broad spectrum antibiotic such as cephalexin is also prescribed to prevent infections along with an antacid medicine such as Lansoprozole for the first few days.
Activity, walking, playing within the house is allowed even the day of surgery by evening but we ask the parents to make sure that the child does not use cycle or any toy on which straddling is needed. Child can sleep on his tummy if he likes to sleep that way. Double diapers prevent too much compression of the hypospadias repair site.
Visits with doctor: We like to see the patients on day 5 after surgery for removal of dressing and for some minor hypospadias repairs we remove the catheter also at the same time. If its moderate or severe hypospadias surgery, we generally remove the catheter after 7-10 days and hence the catheter is removed on second visit then.
Bathing: Once the dressing is out on day 5, the child can be given a short warm tub bath. We ask parents not to use any cotton or cloth for drying the area of hypospadias repair surgery as fibers can stick to the raw area. It is better than after drying the rest of the body the diaper is put on directly and that will dry the area.
Ointments on penis: We advise putting a broad spectrum antibiotic ointment such as neosporin locally on the penis at each diaper change so that it prevents infection and also protects the raw area from sticking to the diaper.

We hope this little primer on care of children after hypospadias surgery helped you. Please feel free to get in touch with us if you need any further information. We hope and pray that your little kid becomes better soon and recovers well from hypospadias surgery.

About the author:

Dr A.K.Singal delivering his talk at ESPU

Dr A.K.Singal is one of the best hypospadias surgeons and Pediatric Urologists in India. He practices in Navi Mumbai, Thane and Mumbai area of India. Dr Singal believes in giving as much information to parents and families as possible about surgery, pre surgery and post surgery course. It helps the parents to be fully informed as he says in his own humorous way- “it decreases my stress and time per consult”

In case you have a child with hypospadias, you can contact him at the following places:

1. MITR Hospital & Hypospadias Foundation

74-90, 1^st Floor, Above IDBI Bank, Chaturbhuj, Shilp Chowk

Sector-21, Kharghar, Navi Mumbai- 410210

Mon & Fri: 5:00-6:30pm, Tues: 12-1pm, Appointments: +91-22-27743558/4229 & 09324180553

2. Fortis Hospital, Mulund

Mulund Goregaon Link Road, Mulund, Mumbai – 400078

Wed & Sat: 4:00pm-5:00pm, Appointments: +91- 22- 43654365; 67994185

3. Jupiter Hospital, Thane

Wed & Saturday, 2:00pm-3:00pm, Appointments: +91-22-21725563/ 55

4. MGM’s New Bombay Hospital, Vashi.

Sector-3, Vashi-400703, Navi Mumbai

Mon, Wed & Fri: 7:00-8:00pm, Phone: +91-22-61526666/ 6675/ 6607

5. MITR Clinic, Vashi

C1/8, Sector- 2, Opp. Green City, Vashi, Navi Mumbai

Tue & Sat: 7:00pm-8:00pm, Appointments: +91-22-65163816 & 9324502572

6. Fortis Hiranandani Hospital, Vashi

Miniseashore road, Sector-10, Vashi, Navi Mumbai

Tue & Sat: 6:00pm-7:00pm, Appointments: +91-22-39199200, 222

Email address: arbinders@gmail.com

Websites:

www.pediatricurology.in, www.hypospadiasfoundation.com, www.mitrhospital.com

Youtube channel: www.youtube.com/pedurohypospadias

Videos:

Single stage repair of severe hypospadias

Interview: Dr Singal speaks about Hypospadias

Contact Form for Hypospadias Foundation

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

June 06 2014

Excellent results of Hypospadias repair surgery – TIP urethroplasty (Snodgrass Repair) for distal penile hypospadias

Hypospadias is one of the most common malformations in boys and affects more than 1 lakh kids in India. At Hypospadias foundation and MITR Hospital, Kharghar, Navi Mumbai, India – we see and manage more than 200 kids every year who have hypospadias and need surgery. These cases are either primary (75%) or those have failed surgery elsewhere (25%)- some of them have failed multiple surgeries elsewhere.

We strongly believe that hypospadias surgical correction should not be taken lightly or casually by any surgeons as first hypospadias surgery is the best chance which the child has. Once the first hypospadias surgery has a complication, more surgeries are needed and still the result may not be optimal. Hence, the surgeon needs to be well trained for hypospadias repair procedure and should have a very keen and passionate interest before he takes up any child up for surgery for hypospadias.

Amongst the various techniques for hypospadias surgery, one of the most popular one is Tubularised Incised Plate (TIP) urethroplasty. TIP repair was first described by Prof Warren Snodgrass and it currently constitutes 70% of all distal and midpenile hypospadias repairs across the world. Due to its universal adoption and remarkable results, it is also known as Snodgrass repair. I had the good fortune of assisting Dr Warren Snodgrass during his multiple visits to India when I was a resident in pediatric surgery at All India Institute of Medical Sciences. I keep bumping him into now and then at pediatric urology conferences, the last one of which was European Society of Pediatric urology Congress in Genoa Italy. We received the best paper award at the conference and it was nice to see Dr Warren Snodgrass applauding us.

While TIP repair or Snodgrass urethroplasty has excellent results, case selection before surgery is very important. The criteria are:

Distal or midpenile hypospadias
Mild to moderate chordee which is correctable
Wide pink elastic urethral plate.

In certain selected proximal hypospadias, Snodgrass repair can be used but on a personal level- a long Snodgrass repair may not be the best option in most cases. We have started using Onlay Island flap repair in most of our proximal hypospadias and all distal/ mid penile hypospadias which are unsuitable for TIP Urethroplasty.

Steps of surgery:

Degloving the penis and chordee correction – straightening of the curvature of the penis
Midline urethral plate incision
Neo-urethra formation on a catheter
Second layer coverage with either a dartos flap or spongiosum
Penile skin cover with Byars flap which helps in creating a midline closure on underside of penis. After the healing is finished, penis looks like just a circumcised penis. In some selected cases Prepucial reconstruction can be offered.

You can watch the video of a Snodgrass Urethroplasty for a distal penile hypospadias here.

In my experience as an expert hypospadias surgeon, while doing TIP urethroplasty everything has to be done meticulously to prevent complications. If I have to narrow down on two things which have really lessened the complications of hypospadias repair with Snodgrass urethroplasty at our centre are:

Fashioning a wide caliber neo-meatus- so that there is no narrowing later on
Providing a second layer cover on new urethra with either spongiosum or a dartos flap.

Master Soham’s parents stay in Latur, Maharashtra and their son was diagnosed to have a distal penile hypospadias at birth. Worried about multiple surgeries and poor outcomes for hypospadias repair- They searched for the best hypospadias surgeon on the internet and landed up in our pediatric urology clinic at MITR Hospital in Kharghar, Navi Mumbai. We did the surgery using a Snodgrass repair technique in First week of May 2014. The surgery went well and child was discharged the evening of surgery. The dressing and catheter were removed 5 days after surgery and now one month after followup the child has an excellent outcome after hypospadias repair surgery. The cosmetic appearance is excellent with a meatus at the tip of penis, straight penis and just a circumcised appearance.

Good cosmetic outcome after single stage hypospadias repair surgery

Parents are also happy and overjoyed.

Happy parents – after successful hypospadias repair surgery

If you wish to consult Dr Singal you can fill up this contact form here:

http://hypospadiasfoundation.com/contact-patient.htm

Or call up Dr Rajkumar at +91-9821261448 to discuss anything

Contact Form for Hypospadias Foundation

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

June 06 2014

Checklist before Hypospadias Repair Surgery

Hypospadias Foundation starts Clinic for Hypospadias Treatment & Surgery in Bahrain

Hypospadias is a birth defect which affects a vital organ of the body- Penis. Penis is the most important organ for urinary and sexual function in a male. Though everyone worries more about sexual function, let me tell you as an expert hypospadias surgeon and a pediatric urologist that both urinary and sexual functions are equally important. While we may need penis for sexual function may be once or twice a day and for maybe for 30-40 years in our lives, we certainly need it for urinary function right from birth till we die and many more times each day. Hence the purpose of hypospadias repair is to set both the functions right in one go- single stage urethroplasty. This includes correction of the curvature of the penis (chordee correction) as well as making a good caliber smooth new urethra till the tip of penis.

But all said and done – Hypospadias treatment means a surgery. Surgery word itself is very scary and it requires a lot of courage and faith for the parents to handover their little one to a surgeon and let me tell you it is not easy for parents to hand over their young kid for a surgery. Lot of things go around in their minds about risks, results and safety of both surgery and anesthesia. Having been a pediatric urologist for almost a decade now, I can feel their helplessness and pain. I never let these feelings overpower me and become a stumbling block to delivering good care. I try to channelize them in the right way and empathize with the family and tell them upfront that I know how they are feeling. And then I tell them what all safety precautions and risk mitigation strategies we have lined up for the hypospadias surgery. My favorite sentence at this juncture is “Safety first everything else later”.

An helmet/ bike analogy works well in this situation: we should always follow all precautions before we go for a bike ride and most importantly wearing a helmet. We may wear a helmet a thousand times and not have an accident but the day we don’t wear it that is the day when we are vulnerable and if something happens- it will be life threatening. Similarly, while doing a hypospadias surgery on a small kid we also take all precautions to make sure that we are absolutely prepared even if something happens in that rare 1/1000 chances.

Hypospadias Surgery Checklist:

Pre-operative fitness tests: A thorough history is taken for any evidence of infection, other illness and any familial disorders. A complete blood count and a urine test is done to check for body parameters. A pediatrician consult is often taken for a systemic examination. Chest xray is no longer recommended routinely before elective surgery if the chest examination is normal.
Pediatric Anesthesiologist: An anesthesia doctor adept at handling kids and regularly giving anesthesia to small kids is the second most important team member after the pediatric urologist.
Hypospadias surgery set: Hypospadias repair surgery require fine, sharp and specialized microsurgery instruments- we keep is separately as a “Hypospadias Set” which is not used for any other surgery.
Operation theatre: OT needs to be clean, sterilized, have all safety equipment for anesthesia, good lighting and all possible infection control measures.
Antibiotic dose just before surgery: We give a dose of injectable broad spectrum antibiotic just before starting the surgery as an infection prevention measure.
Trained staff: Well-trained nursing and junior doctor staff is needed both while assisting surgeries as well as post-operative management, since at Hypospadias foundation at MITR Hospital, Navi Mumbai, India- we do more than 150 hypospadias repairs every year- even the ward assistants know the care of these babies after surgery.
Standardised protocol of surgery: This has been covered in another blog- read it here.

As a Pediatric Urologist and Hypospadias Specialist, I feel overwhelmed when parents trust me and handover their little ones under my care. It is a big responsibility and I try my best to handle them with care. Trust and faith that everything will be fine goes a long way in finding a cure for hypospadias. After all we are all instruments of god trying to do our best. As long as the intentions and efforts are honest, the results will also be good.

About Dr A.K.Singal: Dr Singal is a renowned and top pediatric urologist & one of the best hypospadias surgeons in India. He is well known for single stage hypospadias surgical corrections. He operates children with hypospadias at his centre @ Hypospadias Foundation at Kharghar Navi Mumbai, at MGM & Fortis Hospitals in Vashi, at Fortis Hospital in Mulund, Mumbai and at Jupiter Hospital in Thane.

Dr A.K.Singal during Hypospadias surgery

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

Watch videos on our Youtube Channel:

https://www.youtube.com/watch?v=HGRDZGXlffY

https://www.youtube.com/watch?v=M9_buN10lUE

May 05 2014

Complications after Hypospadias Repair Surgery in children

Hypospadias repair surgery is a very delicate and demanding surgery. It tests the ingenuity of the hypospadias surgeon, surgery skills and most importantly experience. We have realized that hypospadias repair procedure is not a surgery which can be done casually or as one of the many surgeries which a surgeon does. Best results of hypospadias surgeries are seen only when the surgeon dedicates his time and energy in pursuing the art and science of hypospadiology. Results keep on improving day by day and year by year. With more than 600 hypospadias repairs done over last 5 years, Hypospadias Foundation at MITR Hospital, Navi Mumbai, India provides the best results in hypospadias surgeries in south East asia. Children have travelled from all over India and other countries such as Nigeria, Greece, Bangladesh, Iraq, UAE to get treated under Dr Singal’s care for hypospadias.

To get the best outcome in hypospadias, it requires a big team effort which includes hypospadias surgeon, assistants, well trained OT staff and post-surgery caring staff.

No surgery is free of complication and complications happen even in the best of hypospadias surgeon’s hands though they keep in decreasing with advancing experience. Whenever we see any child with hypospadias in our clinic, we make sure that we discuss in detail about the possibility of complications and the post hypospadias surgery outcomes. Some of these we discuss it further here:

Immediate complications after hypospadias repair:

Bleeding – Penis is a very vascular organ with a lot of blood supply. Since hypospadias surgery involves lot of dissection of penis and making of various flaps, suturing them back in proper way is very vital in preventing this complication. The bleeding is usually minor and stops in 2-3 days. Earlier we used to apply heavy and tight dressings after hypospadias surgery but now we have realized that these actually delay healing as they compress the healing tissue. So presently the dressings which we use are very soft and light.
Infection- After any surgery, the immunity of the body goes down plus there is raw area which invites growth of infection causing bacteria. Fortunately, when we do hypospadias repair in children, infection is very rare and even if it occurs is usually superficial and resolves with antibiotics. Various preventive actions are taken before hypospadias repair such as very sterile techniques in operation theatre, broad spectrum antibiotic at start of surgery and 8 hours after surgery, oral antibiotics after surgery and careful handling post-surgery.

Short term complications after hypospadias repair:

Urethral Fistula: Fistula implies leakage of urine somewhere from the newly formed urethral tube below the tip of penis. This occurs because of improper healing resulting from poor blood supply, infection, tight stitches or just poor surgical technique. Sometimes the urethral fistula after hypospadias surgery may heal by itself but mostly it requires surgery which is recommended only after 6 months of first hypospadias surgery. Fistula occurrence depends on experience of the hypospadias surgeon, severity of hypospadias and technique.
Meatal stenosis: This refers to a tight urinary opening after surgery of hypospadias. This can be seen even 2 weeks after surgery and may need regular calibration or minor cut back procedure called meatotomy in some cases.
Diverticulum: This refers to formation of a baggy distended urethral tube and is visible during passage of urine. This may be seen after an onlay flap repair for hypospadias as the skin flap expands and balloons during passage of urine. With careful trimming of the flap during surgery, this has become much less common and occurs in less than 1% of cases after hypospadias surgery.
Stricture: Sometimes during the healing phase, the new urethral tube may become narrow and cause obstruction to urine flow. This is noticed by poor stream, straining (application of force) during passage of urine and long time taken to pass urine. This may require further treatment in form of dilatation or a second surgery some months later.
Dehiscence/ breakdown: Very rarely, the whole repair may breakdown due to poor healing, infection or loss of blood supply requiring more surgeries. This is very uncommon and unfortunate event necessitating a complete redo repair of the hypospadias.

With the newer techniques of hypospadias repair and growing experience of hypospadias surgeons, the complications have become much less common after hypospadias surgery and even when they occur they can be managed well. It is well said that “the prepared mind never knows much trouble”. Once we know that complications can occur in any surgery and be prepared for them, it is much easier to initiate preventive action during surgery itself. Also, it is vital to identify complications earlier so that they can be managed well in time before any long term damage occurs.

About the author:

Dr A.K.Singal is a Pediatric urologist and is renowned as one of the best hypospadias surgeons in India for his dedication towards Hypospadias and excellent results of hypospadias surgery. He has been an invited speaker in various national and international medical conferences and workshops for hypospadias. He is also the founder of Hypospadias Foundation – an organization dedicated to best of care for children with hypospadias. Dr Singal practices art and science of hypospadias treatment in Mumbai and Navi Mumbai area of western India.

Visit Hypospadias Channel https://www.youtube.com/user/pedurohypospadias

Watch videos of Hypospadias surgery by Dr A.K.Singal

https://www.youtube.com/watch?v=HGRDZGXlffY

https://www.youtube.com/watch?v=M9_buN10lUE