International Patients
+916262690790

Tag Archives: Urethroplasty

HomeHypospadias Foundation   Urethroplasty
May 05 2013

Increasing incidence of Hypospadias

Author Dr. A.K.Singal Categories About 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.

Contact Form for Hypospadias Foundation

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

    Attach Documents (pdf | jpeg | mp4)
    (upload size upto 5mb)

    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.

    Contact Form for Hypospadias Foundation

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

      Attach Documents (pdf | jpeg | mp4)
      (upload size upto 5mb)

      November 11 2012

      My child is very young! Is it a safe age to do hypospadias surgery?

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

      One of those questions which parents often ask and which is probably one of the most difficult to answer. But none the less the Question requires its due answer! To start from the basics, Hypospadias is a condition which is generally diagnosed immediately after birth by the pediatrician / neonatologist. The anomaly is very evident by an incomplete prepuce (foreskin), bare glans (head of penis), often a bent penis (called chordee) and misplaced urinary opening. Mostly it is an isolated anomaly but sometimes there may be an associated undescended testis with hypospadias. Since hypospadias is diagnosed at birth, ideally the child should be referred for a surgical opinion from a pediatric urologist or a surgeon trained in doing hypospadias surgery in the first few months of life. Early referral helps as the parents can then plan their lives around treatment of hypospadias. Hypospadias is a problem that always requires surgery called urethroplasty except in very minor varieties such as glanular hypospadias without chordee. It has been shown in multiple clinical studies that children do better when they are operated for hypospadias in infancy itself, ideally around 6-12 months of age. The reasons for these recommendations are multiple:

      1. At this young age the tissues are very soft and tend to heal very well after surgery.

      2. Emotional and psychological issues around getting operated in genital area are non- existent at this age.

      3. Once the surgical result has been good – children at a later age don’t even notice or come to know that they ever had hypospadias as there is hardly anything to differentiate these children from other children. For most of the distal and moderate hypospadias, penis after surgery just looks like a circumcised penis. There is also a debate whether these children should actually be told that they had hypospadias earlier on in their life.

      4. Incidence of wound infection, post surgery bleeding etc are much less at younger age as bacterial colonization is much less.

      5. Post- operative pain and erections are less common at this age.

      6. Management of a small child in diapers and urinary catheter is much easier in infancy. Typically we use a double diaper care where the catheter is brought out through a small hole in the inside diaper to drain into the outer diaper. The inner diaper remains dry and thus prevents rashes and outer diaper is changed whenever it gets wet with urine. In an older child, diapers are very difficult and bulky to use.

      Considering all this, the general consensus of American Academy of Pediatrics is to recommend surgery between the ages of 6 months to one year. At hypospadias foundation and MITR Hospital, we have been operating children around the age of 6-9 months for the last few years with excellent surgical results and happy parents. Once the surgery and the post operative recovery period is over, parents often come and tell us that it was a good decision that they got their kid operated at this early age and now all their worries are over. Some of the parents still worry about getting their kids operated in infancy and come at a later age for surgery. We and the staff can then see the difference in the recovery and post operative issues when compared to younger kids undergoing hypospadias repair. Another way to look at this is that a child with hypospadias will always need surgery, this is a condition which will never get better on its own. The longer we wait, more the parents will think about it and feel anxious. So earlier dealt with, the better it is for everyone. It is definitely better for the kid but it is in a way better for the family and parents as well. And surely it is better for the doctor as his job is to give the best results and post operative comfort.

      Contact Form for Hypospadias Foundation

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

        Attach Documents (pdf | jpeg | mp4)
        (upload size upto 5mb)

        November 11 2012

        Don’t give up hope on Failed Hypospadias

        Author Dr. A.K.Singal Categories Uncategorized

        This is an interesting and inspiring story and I thought I will share it with everyone who has an interest in the field of hypospadias.

        About 6 months back, a 14 years old boy was brought all the way from Nasik to my Pediatric Urology clinic at MITR Hospital in kharghar, Navi Mumbai. The parents did not seem to very well educated and were from a farming background. The father was in some class 4 government job. I was wondering why they would travel for 8 hours to a small place like kharghar to see me. Also the age seemed to me a little bit older than the usual age which I see in my clinic. I was intrigued.

        The boy seemed little uncomfortable and had furtive glances here and there. Parents and relatives were fidgety too. The consultation began – I asked what brought them to Kharghar. They said that their kid has hypospadias and has undergone 5 surgeries till now but still passes urine from below. I asked them “how did they find me”. They said maternal uncle of the boy knows internet and found me while looking for information about hypospadias. So there it was Internet the great enabler at play.

        I went through the case records dating 10 years back. The kid was born with scrotal hypospadias and underwent first major surgery at 2 years of age to straighten the penis (chordee correction) at a top medical college at Mumbai. Post that there were multiple attempts to make a new passage initially using native penile skin and then lining of urinary bladder twice and finally skin graft. Everything had failed and the last surgery was about 5 years back when it was told that there is no hope of the boy having a normal urethral opening at tip of penis. Now I knew the reason of furtive glances and fidgety mannerisms.

        On examination, the boy had the urinary opening right near the anus, the penis was still slightly bent (chordee) and there was lots of scarring on underside of penis with deep pits and ragged skin edges. Further there seemed to be a couple of blind passages and left testis also looked higher in position, may be it was caught up in the scar process. Since the opening was even behind the scrotum, the child had to sit in the toilet and pass urine. Overall, the case seemed like mother of all hypospadias.

        I counseled the parents and set out a planned staged correction of hypospadias. I told them it will be tough and they will need to be patient and have faith.  The plan was to bring him back to his original anatomy first and the reconstruct the entire new urinary passage. As the first stage, I planned to remove all the scarred skin and straighten the penis. In the raw area thus created I was planning to put buccal mucosa graft which is nothing but the inner layer of skin inside the mouth more specifically lips and cheeks. This buccal mucosa graft takes about 3-4 months to heal and then we planned to use this patch to create a new urinary passage. This would give a sure result and the buccal mucosa graft being moist and soft would not have any issues being in touch with urine. Also there would be no hair growth inside the passage in the future.

        Well, the parents were convinced because probably I was the first hypospadias surgeon to offer them any hope. So we all set out on our task, an uphill journey.

        We took up VW for first stage surgery – expecting about 4 hours of surgical time. But we ended up consuming about 7 hours by doing the following

        • Cystoscopy and ascertaining usable urethral passage
        • Excision of all scar tissue on underside of penis
        • Straightening the penis – chordee correction
        • Closing the perineal urethrostomy and establishing a penoscrotal meatus.
        • Correcting the penoscrotal transposition
        • Left orchioexy was needed as the left testis was caught in the fibrosis
        • Buccal mucosa graft

        But we were satisfied at the end of it all. We could not think of a shortcut as the child had been through a lot. The child remained in the hospital for 7 days and the graft healed very well. At removal of catheter, he was able to pass urine from the penoscrotal meatus without difficulty and was finally able to stand up and pass urine without wetting his pants. I could see the change in his behavior and he seemed more interactive now with me and the hospital staff. We had moved forward by an inch I guess!

        4 months later we admitted him again for second stage urethroplasty. The previous graft had healed very well. We could easily make a new urethra just rolling the previous graft plate. This was done over a 12 French silicone catheter without any stress. To ensure full healing we also used a tunica vaginalis graft from the right testis to cover up the suture line.

        As I write, the child has finished one month follow-up after urethroplasty surgery and is recovering well from the surgery. He is passing urine currently from the tip meaning the repair is holding well. The final result is yet to be seen and may be another minor procedure may be needed but the journey has been great. Our mood is upbeat and we are sure that we will reach the destination this time or another short journey may be needed 3 months from now. The fact of the matter is that we enjoyed the journey.

        It is challenges like these when everyone else has given up, we still gear up and try to do our best for these kids. We may not pass in one attempt but eventually we will. Even if 20% need another surgery that is still acceptable as the final goal can still be achieved.

        Contact Form for Hypospadias Foundation

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

          Attach Documents (pdf | jpeg | mp4)
          (upload size upto 5mb)

          1 2 3 4 5 6