Watch Buccal Mucosa Graft Urethroplasty Video here:

Watch Two staged Buccal Mucosa repair surgery in a child:

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:

1. 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.
2. 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:

1. 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.
2. 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.
3. 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.
4. 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.
5. 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

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

———————–

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

——————————————————————-

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

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

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.

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.

Every year more than 100,000 (1 lakh) boys are born with hypospadias in India.  It is s staggering number.

This incidence has been calculated from birth rate for male babies according to Census 2011 and considering that the worldwide accepted incidence of hypospadias is around 1/150 male births. Further we have adjusted this for infant mortality rate. Though our own research in a population study done by Hypospadias Foundation in Vashi & Nerul areas of Navi Mumbai has shown an incidence of hypospadias around 1/126 male births, the base population was only  1200 births which was not very big, hence we did not use this figure.

At Hypospadias Foundation, we are concerned about this increasing incidence of hypospadias across the globe and we are planning to devote time and resources towards research. At the same time, even if we ignore minor hypospadias and those babies without chordee, in whom we can avoid surgery, still about 70,000-80,000 babies will need hypospadias repair surgeries in India every year.

In India, hypospadias repair surgeries are performed by pediatric urologists (wherever available), pediatric surgeons, urologists as well as some plastic surgeons. Some of these surgeons have learnt the art of hypospadias surgery with a formal pediatric urology training while others have gained experience due to their personal interest and have achieved good results. Fortunately, there are short team visiting courses available at some international centres  and also with the availability of good learning resources on internet, surgeon with special interests in hypospadias can explore multiple avenues for training. Infact the current generation of hypospadias surgeons is learning quickly and also starting their careers at a better knowledge base than surgeons who were learning hypospadias two decades back. Newer instruments, newer surgery techniques and sutures have improved the hypospadias repair outcomes.

At centres like Hypospadias Foundation at MITR Hospital, Navi Mumbai, India – a team  of two surgeons with special interest in Hypospadias – Pediatric Urologist & Hypospadiologist- Dr A.K.Singal and adult urologist – Dr Manish Dubey- work together to enhance the outcomes of surgery both in in children as well as adults with hypospadias. While the aim of the team is to spread awareness and also provide for early surgery in infancy for children with hypospadias, they are also reaching out gradually to many older children and adults with failed hypospadias repairs, persisting or residual hypospadias issues. At Hypospadias Foundation, almost every week, the team gets to see an adolescent or an adult with persistent hypospadias issues such as chordee, urethral fistula, urethral stricture, or poor cosmetic outcome such as buried penis. Some of these patients have multiple problems either due to partly or improperly repaired hypospadias in childhood. These cases are looked after by the team with special attention and effort. You can see such a cases:

14 years old Multiple failed hypospadias surgeries in childhood

With growing team and experience, the number of children and adults undergoing hypospadias surgery at Hypospadias foundation have steadily increased over the last five years. This year in 2013, we will finish with around 150 hypospadias surgeries and though it is good but it not even 1% of the total burden in India. We hope to start training pediatric surgeons and urologists so that within India there is facility for budding surgeons to learn the state of art hypospadias surgery.

Healthcare and specifically surgery is all about trust and for complicated diseases like hypospadias it takes time to achieve trust. Every single child who has undergone a successful surgery at Hypospadias Foundation, the family has spread the goodwill and good word about the dedication of our team.  In the last two years, we have been lucky to be a part of treatment process and lives of lot of outstation and international patients – some have come in from Surat, Jalgaon, Nasik, Kolhapur while others have travelled even from Delhi, Ahmedabad, Bangalore, Jaipur and even as far as Jammu or Calcutta. Internationally, we now offer assistance to 1-2 patients every month from countries like Sri lanka, Bangladesh, Pakistan, Nigeria, Kenya, UAE and Congo. Most of the patients who travel these large distances are either failed hypospadias or complex hypospadias who haven’t been able to get satisfactory counseling or answer to their problems.

Our team at Hypospadias Foundation helps the families with email guidance, online consults, follow-ups and planning travel and surgeries according to availability of Dr Singal and Dr Dubey.

You can watch Videos of Hypospadias Surgery on our youtube channel:

Hypospadias Channel

Videos:

Distal penile hypospadias repair

Severe Hypospadias single stage repair by Dr Singal

Contact Hypospadias Foundation

Dr A.K.Singal can be contacted at

1. MITR Hospital & Hypospadias Foundation, Kharghar – 022-27742558/ 4229  & 9324180553

Mon/ Wed/ Fri 5:00-6:00pm

2. MGM Hospital Vashi – 02261526666, 6607

Mon/ Wed/ Fri 7:00-8:00pm

3. MITR Clinic, Vashi- 02265163816, 9324502572

Tue/ Saturday 7:00-8:00pm

4. Fortis Hospital, Sector-9, Vashi- 02239199222, 200

Tue/ Saturday 6:00-7:00pm

Watch our youtube channel for videos of Hypospadias surgery – Pediatric Urology & Hypospadias Channel

You can write to us at dr Singal’s email Id – arbinders@gmail.com  for a second opinion or guidance.

Last Monday was like any other Monday. My pediatric urology clinic was full with appointments and I was getting into the rhythm of seeing children with complicated urinary problems and hypospadias. A young couple walked in with twin male babies, each about 7 months old. The boys were naughty and attentive and soon were soaking in the yellow and pink and greens of my outpatient clinic. I looked at the file and asked them the pediatric urological issues for which they were seeing me that day. They said their kid had hypospadias and both of them had hypospadias infact and they wanted to see a Pediatric urologist. Now that was a shocker!! Though this was not the first time that I was seeing twin boys with Hypospadias, but it was that once in two years phenomenon. And more striking since these boys had exactly the same type of hypospadias- which was distal penile hypospadias with mild chordee. Last year I had treated two brothers with hypospadias but the age was 3 and 5 years and thus difference in age was 2 years. The elder one has a mid penile hypospadias while the younger one had a distal penile hypospadias. I suddenly remembered the dilemmas which face a Pediatric Urologist & a Hypospadiologist while treating siblings with hypospadias.

• Which boy do you treat first – plan according to age – elder first or severity wise and severe hypospadias first and minor later?

• Whether you do them the same day or one after the other or with some gap of days in between?

• How will the parents manage two babies getting operated for the same thing at the same time?

• And if you operate one baby with hypospadias first and second one a few days later- what is the effect on their minds? How do they cope up with a situation where one has undergone a hypospadias surgery and the other one is waiting. Does the second kid get scared seeing the first one in pain after surgery and undergoing hospital visits and checkups? It was a tough situation to be in – for me as a hypospadias surgeon and even more for the parents who will have to care for the children 24×7 after surgery.

After a lot of deliberation, we decided that we do the hypospadias repair one after the other but on the consecutive days at MITR Hospital & Hypospadias Foundation. We admitted the elder sibling (with more severe hypospadias) for surgery on Tuesday morning and surgery was conducted as the first case in the morning. The younger kid was admitted on Wednesday morning and underwent uneventful repair on Wednesday itself. We arranged for two beds in one room so that both of them can share their side of the story. At least here there was no scope of having a feeling of being left out. Both of them for a fact got a HYPOSPADIAS SURGERY. Recovery period after surgery was smooth and both of them were discharged on Wednesday evening. The kids came back for follow-up on the same day after a week and their catheters were removed the same day. The children pee’d and actually compared their streams and for me luckily- both had good thick straight urine streams without any complications. Deep inside, throughout the recovery period, I was a bit worried about a complication happening. Luckily, everything went well and I had two happy kids with me. Now coming back to present case at hand- where I have a set of twin babies with hypospadias. So going by my previous experience, I think we will stick to the same plan. The only advantage here is that the kids are still less than one year of age and they won’t think much about surgery. I am planning to do them on a Tuesday and a Wednesday and then send them home on Wednesday itself.

Medicine lends itself to unusual off the script events every day and as we say every patient has a story. For us at Hypospadias Foundation – we believe every child hypospadias has a story with happy ending.

Hypospadias is recognized as a pediatric urological disorder, the incidence of which is on the rise over the last two decades. While researchers and clinicians agree that the detection and diagnosis rate of hypospadias has increased due to increased awareness, it is also certain that there are other factors which are contributing to the increased incidence of hypospadias.
The last few studies have noted the incidence of hypospadias to be almost 1/150 newborn boys. This is substantial as compared to what was reported to be 1/250 boys two decades back.
To understand what leads to higher incidence of hypospadias we have to understand in a simple language how Hypospadias happens. During the critical phase of sex development in the baby during pregnancy – at around 8 weeks both the male and female sexual organs look similar. Between 8-14 weeks, under the influence of male hormones produced by the testis (Testosterone and Dihydrotestosterone, also called androgens) these organs develop into male organs. These hormones cause the genital tubercle to enlarge and become a penis and at the same time the urinary passage (called urethra) starts developing on the underside of the penis and closes like a zipper from the bottom to the tip of penis. All this is a very intricate coordinated activity and guided by levels and actions of male hormones. Blockage of action of these hormones or lower levels in this critical phase lead to an incomplete urethra resulting in hypospadias. Thus, the urethra falls short of the tip and urethral opening remains on the underside of penis.
Recent research has shown that the rising levels of chemicals in environment so called Endocrine disruptors have been responsible in some ways for this rise in the incidence of hypospadias and other reproductive anomalies such as undescended testis, low sperm counts and testicular cancer. These chemicals come from pesticides, colouring agents, dyes, hair sprays, plastics used in cars, bottles etc. They are all around us and it may take us many years to see their full blown effect on human bodies. Even hormonal treatment for infertility such as IVF, smoking and excessive analgesic use during pregnancy has been shown to have increase the risk of hypospadias. In an environment loaded with pollution and unknown synthetic chemical residues, we can never ascertain fully how the cumulative effect of all these agents affects the gentle developing organs of the baby.
We recently conducted the largest study yet in India about finding out the incidence of hypospadias and undescended testis in India. We found that incidence of undescended testis has increased to almost 5% and hypospadias 1/126 babies in India. Earlier reported incidence for undescended testis was 1.6% in 1971, so it has almost tripled in last 40 years. Hypospadias incidence has not been reported in India yet.
Extrapolating these figures, there will be around 110,000 babies born with Hypospadias every year in India and they will need counseling and proper treatment. Similarly, almost 7 lakh (700,000) babies will be born with undescended testis and almost 30% of these – almost 2 lakh babies (200,000) will need surgery for undescended testis every year. These numbers are not small by any stretch of imagination and call for further research and awareness among general public, governmental organisations as well as doctors.
Dr A.K.Singal, Pediatric urologist & Hypospadiologist, presented these findings at European Society of Pediatric Urology Annual Congress in Genoa, Italy in April 2013. The study was very well appreciated and we won a prize also for it.
At Hypospadias Foundation, we have committed ourselves to excellent clinical care of children with Hypospadias but equally importantly towards meaningful clinical research in the field of Hypospadiology also. In India typically we follow data from the west as we do not have means to collect our own data or just that our priorities towards care for the large population are so huge that we do not have time/ resources for research. Since Hypospadias Foundation is an autonomous body, we have made research our important goal and made it a missionary zeal to collect our own data within India, learn from our own data and then share the research results with the rest of the world.
Medical Science moves forwards by doing clinical work and also analyzing that we are doing today is better than what we did yesterday. But if we can use scientific research tools to find out why hypospadias happen, why are they increasing and what can be done to decrease the incidence – that will be the most fruitful use of science. Prevention is always better than treatment.

Why is dressing needed after hypospadias surgery (urethroplasty)?

As after any surgery, a dressing is required after hypospadias repair as well and the reasons for this are many.

• The dressing helps to prevent infections by creating a physical barrier as well as supports the penis in the healing phase.
• Penis is an organ which has a tendency to swell up after surgery or any trauma and thus a dressing helps to support the organ in the healing phase after hypospadias surgery.
• Besides these two major goals, some surgeons use the dressings to prevent bleeding after surgery but with the refined techniques and more experience, bleeding has become less common issue surgery and we at hypospadias foundation generally use a very loose dressing as prevention of bleeding is generally not the goal for the application of dressing.

When we were in surgical training, we had a standard firm elastocrape dressing which used to be applied tightly and was resultantly difficult to remove. The advantage, though, was that it would remain in place without the risk of getting dislodged. On a personal front, as a resident doctor asked to remove those bulky sticky dressings, I was never happy with the dressing as it was difficult to apply, difficult to remove and I felt that it would cause too much of pressure on the healing tissue at the cost of impairing circulation. Also the healing area will not get air to breathe. I was worried that this may result in poor healing as well.

Over the last few years though the primary goals of dressings have remained the same, the dressing after hypospadias surgery itself in our practice has become very easy to apply and remove.

What we use is the following:

At the end of hypospadias surgery, we put a transparent cling wrap kind of dressing called – Tegaderm film- on to the penis – the operated site. This is light in consistency, does not stick to the tissues, is easy to remove and it allows passage of air through it thus aiding in healing.

Over the Tegaderm film, we apply a couple of rolls of thin white gauze just to support the penis and this layer is kept loose and just functions as a soft scaffolding.

A small piece of sticking tape called micropore is applied to hold the gauze piece and the catheter in place and this step finishes the dressing.

In some children, if the dissection has been extensive into the scrotum or the penis length is short we apply a sandwich type of dressing over the whole area instead of a rolled dressing.

Double diaper care- finally the catheter is brought out through a small hole in the inner diaper and left to drain in the outer diaper. Double diapers also help in keeping the area snug and dry during the healing process while allowing the children freedom of movement.

We believe a loose dressing after hypospadias surgery allows good blood circulation to operated area after surgery and thus faster healing. Also, we have observed that the pain is much less with this type of dressing. This dressing is also very easy to remove in the outpatient department during follow up.

What can go wrong with hypospadias dressings?

Dressings can get dislodged fairly frequently after hypospadias surgery. If this happens during first 2-3 days we like to do the dressing again in clinic. But if this happens after 3 days, we just remove the dressing completely and apply antibiotic ointment on the operated area 3-4 times a day and at every diaper change.

When do we remove the dressings

We generally remove the dressings on day 5-6 but in certain distal hypospadias we like to remove the dressings along with the catheter on day 7 after surgery. Removing them together avoids one opd visit for the family.

How are dressings removed after hypospadias surgery/ urethroplasty?

Dressings are removed in the outpatient unit by the junior doctor or the treating surgeon by gently teasing them out. Sometimes normal saline is used to ease out the dressings by making them wet. We have seen that tegaderm based dressings slip out fairly easily in clinic. The only caution to make sure that the catheter is not accidentally pulled up while loosening the dressing.

What happens if there is bleeding into the dressing?

Minor bleeding after hypospadias surgery is fairly common and happens as penis has very robust blood supply. Generally this occurs as a small amount of blood spotting or drops of blood at the tip of penis. If the bleeding stops by itself, nothing needs to be done and this is generally the case. If the bleeding is more in quantity, we ask the parents to visit us and a tighter dressing may need to be applied.

What happens if there is urine leakage into the dressing?

Small amount of urine leakage by the side of the catheter into the dressing is common. If there is lot of urine leakage by the side of the catheter then this means that the catheter may be blocked. The surgeon can then flush the catheter to relieve the block and the leakage will stop.

What happens if there is potty staining of the dressing

Sometimes the children may have loose motions after hypospadias surgery due to side effects of the antibiotics. These may then leak and stain the dressing. In such a case you should wash away the stools and visit the Hypospadias Foundation/ Mitr Hospital to get the dressing changed or removed. If dressing is left potty stained for long, this may allow the bacteria in potty to cause infection in the freshly operated hypospadias.

What care to take after removal of dressing

Child can be given warm tub bath twice a day and an antibiotic ointment should be applied on the operated site 4-5 items per day.  Inner Diapers should be changed at least 2-3 times per day and outer ones as soon as they are full with urine.