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April 04 2021

Single Stage Repair Surgery for Distal Hypospadias and Penile Torsion

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

Hypospadias Foundation starts Clinic for Hypospadias Treatment & Surgery in Bahrain

10-month child was brought with complaints of deviation of urine stream and abnormal location of meatus. On clinical examination there was distal penile hypospadias with severe penile torsion measuring 90 degrees to the left. We planned a single stage correction for both Penile torsion and distal penile hypospadias.

Penile torsion

Notice Penile torsion to left

Distal Hypospadias with Penile torsion

Surgery Steps:

Marking of the degloving incision. Local anaesthesia was infiltrated at the marked incision site. Complete degloving was done and chordee was assessed using artificial erection test. 30-degree chordee was noted. Chordee correction was done by Tunica albuginea plication at 12’O clock on the dorsal side. Following this correction, chordee was reassessed and no chordee was noted. Urethroplasty was started by incising urethral plate in the midline. Urethroplasty was done over a 7Fr Infant feeding tube with 6-0 PDS continuous sutures. Dartos flap was harvested for extra coverage over urethroplasty which was sutured using 6-0 PDS. Penoscrotal web correction was also done. Excess skin excised and sutured using 5-0 vicryl rapide. Skin flaps were rotated and adjusted to correct the penile torsion and sutured all around using 5-0 vicryl rapide. Dressing and catheter were in situ for 7 days. Following 7 days, dressing and catheter was removed.

Penile torsion and Hypospadias repair

Finished Hypospadias and Penile torsion surgery

Final outcome of correction of penile torsion and hypospadias

Results

The Final result was very gratifying with a straight penis without any torsion. The child was passing urine in good stream in straight axis without any discomfort or pain.

About Hypospadias repair and penile torsion

Penile torsion is a condition wherein the penis is rotated or twisted on its axis. The penile torsion is more commonly to the left. Many a time penile torsion may not be detected till a circumcision is planned or foreskin is retracted.

Penile torsion may be associated with hypospadias and/or chordee (penile curvature). With hypospadias, penile torsion is mostly associated with distal penile cases.

Based on the degree of glanular rotation, penile torsion can be classified as mild, moderate, and severe. It is mild if its less than 45 degree, moderate if it’s between 45-90 degree and severe if more than 90 degree.

Penile torsion in majority of cases (>85%) is between 10 to 20 degree. If it is a moderate or severe degree of torsion, urine stream may be deviated to one side.

Surgical intervention is not always required in isolated penile torsion. The indications for surgical correction are cosmetic, functional, or sexual. When penile torsion is associated with hypospadias, it should be corrected along with Hypospadias repair or urethroplasty at the same time.

About Hypospadias Foundation

Hypospadias foundation is a centre which provides personalized and best quality care for children and adults with hypospadias. It is one of the best hospital centres in India and world for surgical treatment for hypospadias in adults and children.  Our dedication in the field of hypospadias has helped us achieve excellent outcomes in these patients. We treat children and adults not only from various parts of India but also from more than 25 countries all over the world. Hypospadias foundation is located at MITR hospital in Kharghar, Navi-Mumbai, Maharashtra, India. Every year more than 200 surgeries for hypospadias are performed at MITR hospital and Hypospadias Foundation

Contact us:

For appointment kindly contact us at the contact details given below.

  • MITR hospital & Hypospadias Foundation, Kharghar, Navi Mumbai, India
  • MITR Clinic: C1/8 Ground floor, Sector-2, VashiCall

Call for appointments: +91-2227743558/ 27744229/ 39/69 and +919324180553.

Or you can fill up this form- Contact form for Dr Singal

January 01 2020

Dr A.K.Singal presents his work at Hypospadias World Congress at Childrens Hospital of Philadelphia, USA

Author Dr. A.K.Singal Categories About Hypospadias, Cases worth noting, Hypospadias, Hypospadias Specialist, Hypospadias surgeon Mumbai, Hypospadias Surgery, Uncategorized

Hypospadias Foundation starts Clinic for Hypospadias Treatment & Surgery in Bahrain

Dr A.K.Singal was an invited speaker at Hypospadias World Congress at Children’s Research Center at Children’s Hospital of Philadelphia, USA, held between 30th October 2019-1st Nov 2019. Dr Singal presented four papers on hypospadias treatment and moderated scientific sessions during the conference.

The conference saw participation from more than 150 pediatric urologists and hypospadias specialists from across the world. The conference solely focussed on hypospadias. Various aspects of hypospadias were discussed such as etiology, diagnosis, hormonal tests and supplementation (testosterone injections), surgery techniques and complications/ results of hypospadias surgeries.

Dr A.K.Singal

Dr A.K.Singal

Dr Singal with Dr Long & Dr Zaontz

Dr Singal presented the following lectures and papers in the World Congress:

  • Buccal inlay graft for failed hypospadias- Dr Singal showed technique of buccal (oral) mucosa graft inlay surgery and its results in failed hypospadias cases.
  • Considerations in adult hypospadias repairs- Adult hypospadias are difficult to manage especially if the surgery done in childhood has failed. Dr Singal showed innovative surgery techniques for such adult hypospadias cases for best outcomes.
  • Reimagined Byar’s flaps for staged hypospadias repairs- For hypospadias with severe chordee, it is important that the penile curvature gets fully corrected in first stage and then second stage surgery is done for bringing the urethra to the tip of penis. In expert hands the results of two stage surgery for hypospadias with severe chordee is very good. Dr Singal showed finer nuances of surgery to achieve best results to the audience.
  • Parental Awareness survey for families with hypospadias: Families of children or adults with hypospadias are often not fully aware of the extent of disease and what it means in the long run. Dr Singal and his team conducted a study of 150 families to understand about their concerns about hypospadias and their knowledge level about the disease/ surgery.

Overall the three-day conference resulted in great mutual exchange of ideas and also helped younger generation of surgeons learn from eminent faculty from all over the world.

June 06 2014

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

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

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:

  1. Distal or midpenile hypospadias
  2. Mild to moderate chordee which is correctable
  3. 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:

  1. Degloving the penis and chordee correction – straightening of the curvature of the penis
  2. Midline urethral plate incision
  3. Neo-urethra formation on a catheter
  4. Second layer coverage with either a dartos flap or spongiosum
  5. 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

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    June 06 2014

    Checklist before Hypospadias Repair Surgery

    Author Dr. A.K.Singal Categories About Hypospadias

    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:

    1. 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.
    2. 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.
    3. 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.
    4. Operation theatre: OT needs to be clean, sterilized, have all safety equipment for anesthesia, good lighting and all possible infection control measures.
    5. Antibiotic dose just before surgery: We give a dose of injectable broad spectrum antibiotic just before starting the surgery as an infection prevention measure.
    6. 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.
    7. 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

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