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HomeHypospadias Foundation   single stage urethroplasty
July 07 2013

Twin babies with Hypospadias- Dilemmas in management!

Author Dr. A.K.Singal Categories Cases worth noting

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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    December 12 2012

    Dressings after hypospadias surgery – everything the parents should know about!

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

    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.

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      October 10 2012

      Should a distal hypospadias be repaired!!

      Author Dr. A.K.Singal Categories Hypospadias Surgery

      I did not know what was in store for me – there was 6 new patients in clinic and only 4 follow-ups and by the nature of it new patients take more time and follow-ups finish very fast. Anyway, the first patient who walked in was a 3 year old accompanied by young smart looking parents. The boy flashed a big smile and I said hello and he was eager to shake hands. That was a positive sign – Acceptance of me as a friend. Good so far.It was a nice Saturday evening, the watch clicked 7pm and I was in my Pediatric Urology clinic at Vashi with the last 10 urology appointments and was slated to be back home by 8pm.

      Invariably on Saturdays I get late but today I was all energized to finish consultations fast and head back home for a quiet dinner and then catch up on much neglected sleep.

      Then we got down to the business of consultation- the parents had looked up about hypospadias on internet and had found me and then travelled all the way to Navi Mumbai on a Saturday evening for a consultation for their little one who had hypospadias. I examined the eager and cooperative kid- he has a coronal hypospadias with mild tilt of glans (the head of penis). There was no chordee (actual bend of the body of penis) and testes were in normal location. Overall, it looked like a milder distal hypospadias which should be fairly easy to repair with a predictably good result.

      I explained everything about hypospadias – how it happens and how it is repaired and then the QA began. The parents asked – “Is it necessary to repair it? We have heard that it can lead to long term urinary problems and sexual dysfunctions as sometimes the nerves get cut during sensation leading to a numb penis. Also, there are blogs which talk about no need to do surgery in distal hypospadias as there may be long term complications like hair growth, tight passage, fistulas etc.” They had visited an eminent Urologist who had advised against surgery.

      Well, they had done their due research and it was good but sometimes the truth out there may not be whole truth. I had to counsel them and make sure that they know the whole truth while at the same time sounding detached from the whole process. It was after all their kid and their responsibility- my job was to give full, fair and medically sound information and then their job was to make the right decision for their kid.

      So here are the facts as I discussed with them:

      1. As the boy grows and finally the penis size become adult like, the deformity becomes more and more obvious. The glans (penis head) which was tilted will look more and more abnormal.
      2. The prepuce will only be on the top of the head and not on the underside leading to an incomplete prepuce. It looks rather like the head of a cobra in adulthood
      3. The urinary opening will be on the underside of penis and the urine stream will always be downward instead of forward as in a normal child.
      4. The problems as stated above will be more cosmetic than functional but they affect the psyche as he will be able to see that the shape and configuration of his penis is quite different from that of other children. This can lead to deep seated emotional and social withdrawal issues in teenage and adulthood.
      5. Repairs are easier with predictable and better results in childhood. Later on in teenage and adulthood repairs have higher failure rates and pain. Further erections can cause pain and instability in the repaired area after surgery.
      6. The blogs out there contain stories of people who underwent surgery for hypospadias in childhood and now are adults. Thus the care which they received was 20-25 years back. The art & science of Hypospadiology has moved at much faster pace in last two decades and now- the understanding of anatomy of penis & hypospadias is much better, the surgical techniques have evolved and most of the repairs are done in single stage, new instruments for finer surgeries are available, new fine absorbable & non-reactive stitches are available and above all there are doctors who are well trained in managing the children with hypospadias.
      7. Earlier surgeries using skin from scrotum or other body tissues are not done any more so currently any repair causing hair growth in urethra is outdated and not done by surgeons.
      8. Complications like fistula, tight passage (stricture) are less than 5% in experienced, trained surgeons hands for milder distal hypospadias.

      To sum up, it is worthwhile to repair distal hypospadias considering all the above. The science of hypospadias surgery has made sure that the children get the best results for surgery in their early childhood and then live their lives normal without worrying about their reproductive organs.

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        June 06 2012

        Evolution in Hypospadias treatment

        Author Dr. A.K.Singal Categories Hypospadias

        Hypospadias management has undergone big changes in last two decades. The results and outcomes of surgery have improved tremendously making hypospadias management a lesser headache for the doctor and the parents. Two decades back the results for hypospadias surgery were not so predictable and the surgeons and the family all used to be ready for mentally and financially for 2-3 surgeries and that too with suboptimal cosmetic and functional results.

        Some of the things which have helped this change are:

        • The newer techniques of  single stage urethroplasty (hypospadias surgery) such as onlay flaps,  Snodgrass repair and prepucial tube repairs.
        • Newer and finer sutures to do the surgery such as PDS, monocryl and vicryl rapide
        • Fine microsurgery instruments for doing surgery on delicate penile tissues
        • Uniform use of optical magnification by surgeons while doing surgery
        • Day care surgery avoiding long hospitalization and infact the whole focus is on sending the children home the same day in most cases
        • Good antibiotics and  pain relief in post surgery period
        • Early age at surgery – Surgery is nowadays usually done at 6-9 months of age for a child who is otherwise well
        • Trained surgeons and teams dedicating time and energy towards giving a good outcome in children with Hypospadias
        • Surgeons with mindset firmly towards doing a single stage repair. Mindset change has been a key catalyst towards single stage surgeries.

        For a penile hypospadias whether it is mild, moderate or severe (distal, mid or proximal penile), the success rates for a single stage urethroplasty are close to 95% now; meaning that only 5% of the children require a second surgery for urethral fistula and even lesser for a stenosis. This is very heartening and gives confidence to the family as well as the doctor treating children with hypospadias. For such cases, it has become like any other surgery now, the child comes to the hospital on the morning of surgery, gets the surgery done in 1-2 hours, goes home by evening playful, active and pain free. Only thing the parents need to take care is regular medicines and diaper changes. This is certainly a huge step from 1990’s where these kids were kept admitted in the hospital for a week or ten days while they recovered after surgery.

        At home children eat better, feel better, are with family and there are lesser chances of hospital acquired infections with resistant bacteria. Happiness and good food is a key ingredient for a child getting a favorable result and this component is often understated and misunderstood. Keeping the child for a prolonged duration of time in hospital only increases cost of the surgery, amount of medicines used, discomfort faced by family and also risk of hospital acquired infections.

        Surgeon training in Pediatric Urology also has a great bearing on the outcomes of hypospadias repairs. With advancing experience, depth of academic and anatomical knowledge, devotion of time to hypospadias is the key to better results seen for some surgeons. It is often said that in Pediatric Urology specialty, to have good results in hypospadias surgery is often the acid test. It may be easier to excel in Laparoscopy or Endourology but still challenging to provide uniformly good results in hypospadias. The repairs and the depth of knowledge and understanding required is challenging and first few cases are unpredictable with respect to outcomes and a lot of young surgeons get disheartened and stop investing themselves into the art and science of hypospadias management. First few failures often bring out the fears and some surgeons find it difficult to continue in this unsure scenario. I still don’t know a single surgeon who never had a complication with hypospadias repairs or has stopped having complications in hypospadias. They do happen even with the most dedicated & expereinced surgeons as medical science is often an imperfect science thus lending the term “I practice medicine” but with growing volumes or experience and most importantly using the catalyst of dedication the results can quickly become very good, predictable and measurable. The complication rates/ second surgery rates become manageable and suddenly it seems enjoyable.

        It is very important that a surgeon enjoys his work- it should be like meditation while doing surgery wearing magnifying loupes with all the attention solely on a 2 inch area trying to finish the nature’s unfinished business with human hands. When this happens, that is when the results are acceptable to the surgeon and the parents.

        Distal Penile Hypospadias repair surgery by Dr Singal

        Severe Scrotal Hypospadias- Single stage repair by Dr A.K.Singal

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