hypospadiologist Archives - Hypospadias Foundation

January 01 2014

Living with Hypospadias- Adults with 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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October 10 2013

Hypospadias Surgery In 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

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

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

MGM Hospital Vashi – 02261526666, 6607

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

MITR Clinic, Vashi- 02265163816, 9324502572

Tue/ Saturday 7:00-8:00pm

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.

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July 07 2013

Twin babies with Hypospadias- Dilemmas in management!

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.

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May 05 2013

Increasing incidence of Hypospadias

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.

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Contact Form for Hypospadias Foundation

Contact Form for Hypospadias Foundation

Contact Form for Hypospadias Foundation

Contact Form for Hypospadias Foundation