A 8-year-old boy presented with complaints of passing a thin stream of urine from the coronal region and severe abnormal curvature of the underside of the penis even after undergoing 5 hypospadias repair surgeries elsewhere in the past. Distressed parents visited our centre with a hope for correction of hypospadias for their only son. On examination he had scarred skin on the underside of the penis, severe ventral curvature(residual chordee), narrow meatus, poor urethral plate and overriding scrotal skin on the underside of the penis.
We planned a 3 stage surgery due to severe fibrosis and severe residual chordee.
Stage 1: Chordee correction was planned. After degloving we found ventral bands causing chordee. There was a residual band from the tunica vaginalis flap which had been used at the previous centre. Even after dividing this band and all the fibrosis, there was still 60 degree chordee. We divided and mobilised urethra, still there was significant chordee. Hence, we planned a dermal graft augmentation of the ventral corporal body. Skin ellipse was harvested from the inguinal region and was de-epithelialized and defatted. Ventral transverse incision was given at site of maximum curvature from 3 to 9 o’clock. Graft was sutured in place with 6-0 PDS interrupted sutures. No residual chordee was seen on artificial erection test. Skin was closed and dressing was done.
Fig 1: Clinical picture showing scarred skin, narrow and scarred urethral plate, coronal narrow meatus and residual chordee
Fig 2: Complete degloving done and scarred fibrotic tissues noted which were divided. Artificial erection test showed severe chordee of more than 60 degree
Fig 3: Urethral plate was divided and mobilized and Corporotomies done. Persistent chordee inspite of urethral plate division and mobilization. Dermal graft placed at the site of maximum curvature.
Fig 4: Skin closed following dermal graft. 6 months following stage 1 healthy skin on the ventral side with no chordee.
Stage 2: After 6 months, the healing was complete and there was hardly any fibrosis or chordee. We planned the placement of an oral mucosa graft. Midline incision was given and deepened till corpora. Oral graft was harvested from upper and lower lips. The graft was defatted slightly and quilted in place with 6.0 PDS. Pressure dressing was applied and the catheter fixed. The dressing and catheter were removed after 7 days. Post 21 days local steroid massages were started.
Fig 5: In second surgery, chordee was assessed prior to start of the surgery. No chordee noted. Unhealthy skin excised.
Fig 6: 5cm graft was required. Buccal graft harvested from the upper and lower lip
Fig 7: 6 months post buccal mucosa graft placement showed complete uptake of the graft. Lip area healed well with no scarring.
Stage 3: After 6 months, the graft was well healed. It was soft and supple and the surrounding skin was also healthy. We planned to do the final stage- OMG urethroplasty. U shaped incision was made around the graft. The incision was deepened till the corpora. The urethroplasty was done with 6.0 PDS in 2 layers over a 7F catheter. Finally local flaps were used for second layer coverage. Skin closed and dressing was done. Catheter was removed on day 10. Child passed urine in a good stream. Parents were happy with the final functional and cosmetic outcome for hypospadias.
Fig 8: Marking at the margin of the graft. Incision given at the margin and graft tubularized to complete the first layer of urethroplasty.
Fig 9: Dartos flap harvested from the right side and sutured over the urethroplasty. Skin closed using 6-0 vicryl rapide subcuticular sutures.
Fig 10: Catheter was removed on post operative day 14. Child was passing urine in a single straight stream following catheter removal.
Buccal mucosa graft in Redo hypospadias surgery
Hypospadias is a congenital condition with an incidence of 1 in 300 live births. Correction of hypospadias is necessary to achieve as a forward straight stream and an erect penis with no abnormal curvature. First surgery is always the best surgery with the best chance to correct abnormal curvature (chordee correction), creation of urinary passage (urethroplasty) and reconstructing the glans (glansplasty) with minimal complications. Any previous surgery with multiple complications (failed hypospadias repair) is always difficult to treat. The complications which can arise following the hypospadias surgery are residual chordee, extensive fibrosis in the urethral bed, shortage of skin, glans deformities etc . Correcting these is extremely challenging. While some of these complications can be corrected in one stage, most of them require a staged approach.
The above mentioned case is of a boy who had undergone multiple surgeries in the past but had severe residual chordee, scarred tissue on the underside of the penis and passing a thin stream of urine. His surgery was planned in 3 stages. First stage involved correction of residual chordee by excision of all fibrotic tissues from the underside of the penis. A ventral lengthening procedure was done by placing a dermal graft. Second stage involved placing an oral mucosa graft and the third stage was urethroplasty. At last after completion of third surgery he was able to pass urine in a forward straight stream with no complications.
About Hypospadias Foundation
Hypospadias foundation is a centre which provides personalized care for children and adults with hypospadias. It is the best hospital centre 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. Every year more than 200 surgeries of hypospadias are performed at MITR hospital.
Hypospadias foundation is located at MITR hospital in Kharghar, Navi-Mumbai, Maharashtra, India. Dr A K Singal is an expert and top hypospadias surgeon in India. He is a gifted surgeon and his expertise in this area has helped us achieve excellent outcomes in primary and redo hypospadias in children as well as adults.
Dr Ashwitha Shenoy has special interest in treating adults and children with hypospadias. At hypospadias foundation Dr Singal and Dr Shenoy strive towards achieving desired outcomes in children and adults with hypospadias.
Contact us:
For appointment kindly contact us at the contact details given below.
MITR hospital & Hypospadias Foundation, Kharghar, Navi Mumbai – Tue/Sat 4:00pm-6:00pm, Call for appointments: +916262840940/+916262690790 and 09324180553.