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Failed Hypospadias Treatment in India

Failed Hypospadias

Failed Hypospadias is a condition that is quite common in young boys, occurring at the time of birth. Complications may occur if it is not treated. Even though Hypospadias has a very straightforward treatment. What could you do about it? Let’s know more about it.

What is Hypospadias?

Hypospadias is a birth defect that only occurs in Males. The Urethra, responsible for carrying urine outside of the body, develops abnormally instead of the usual location (tip of the penis). Most of the times, the opening of the urethra develops on the underside of the Male genital. However, there are many variations to it, and sometime it can also develop near the scrotum. The further it is from the usual position, the more severe the case could be.

Causes

Like most birth defects, causes of Hypospadias are not exactly known. Abnormal hormone production during pregnancy could alter the development of the reproductive system of the male fetus, which might sometimes result in Hypospadias. Physical damages have been shown to have no correlation with this condition.

Complications

Although there are no dangers to the people suffering from Hypospadias, there are still many complications that could arise in the patients. Some of them include:

  • The irregular location of the urethra opening often leads to difficulty in urination. While it is manageable, it becomes very difficult for the young boys to learn doing it.
  • More often than not, a person suffering from hypospadias has an abnormal penis, mostly with a curvature larger than usual. Not only does it pose problem with erection, it also might lead to low self-confidence of the individuals.
  • Again, the abnormal shape of the penis and the location of the tip of urethra can affect ejaculation, sometimes making it impossible to achieve it. If not treated, it could lead to a problematic sex life and many psychological issues.

Failed Hypospadias Treatment

One has to understand that hypospadias is a condition for which surgery is the only treatment.

In most cases, a single surgery is enough to solve the issue. The urethra is adjusted so that it now points towards the tip of the penis and can work normally.

However, in the more complicated cases, multiple surgeries (in stages) may be required. Tissue grafts might be needed to reconstruct the urethra significantly.

Failed Hypospadias

The primary factor behind the success is the age of the individual. Children are known to have a success rate of about 95%, while it is lower in adults undergoing the same procedures.

The second major factor is the type of surgery undertaken. Repositioning of urethra is almost always successful, as it requires no additional procedure. However, creating a flap or grafts could be tricky and may often lead to complications.

Failed hypospadias surgery can be a major setback for the patients. The complications arising from the surgery may require multiple subsequent surgeries and hence, can impact the patient both psychologically and physically. Psychosexual analysis shows that Men with successful Hypospadias repair always have a better score than Men with failed hypospadias repair.

 

Steps to be taken before repair

The initial evaluation is very critical before carrying out the repair for hypospadias. The past failure has to be analyzed to understand the cause behind it. The most basic step, usually, is to view the complication that occurred with the failure. It could be a stricture, chordee, fistula or persistent hypospadias. Records of previous treatments are a great help in understanding the reason behind the complications, but often the failure occurs many years earlier and records are hard to obtain.

In any case, certain observations must be recorded. These include:

  • Record of urine flow and any obstacles in it whatsoever
  • Penile curvature
  • Difficulty in intercourse and/or ejaculation
  • Any infections in the urinary tract or stones in the urinary bladder

 

Hypospadias repair

There are many ways failed Hypospadias could be repaired. Let’s take a look at them:

 

Stricture repair

People suffering from urethral stricture after a failed Hypospadias operation could get it corrected surgically. A lot depends upon the length and location of the stricture itself. People having stricture that are small and/or located on the outside may require only a single surgery, while people with long and/or inside stricture may require staged urethroplasty along with grafting.

 

Excision and primary anastomosis

EPA is a very effective technique in dealing with stricture that are short and usually on the outside. While EPA is very successful in cases of urethroplasty, it must be used in case of Hypospadias with caution. Hypospadias is known to alter blood supply to the urethra, so it must be kept in mind using EPA. The doctor must ensure that the blood flow from the penile arteries must not be affected.

 

Preputial skin flap

While use of skin flap is common in most surgeries, it is rarely adopted in cases of Hypospadias repair. The reason is the lack of enough foreskin due to previous Hypospadias surgery, among other issues. For this reason, use of preputial skin flap has a high failure rate. However, if you have enough foreskin for creating skin flaps, then this technique could be used.

Single-stage buccal graft repair

In cases of long strictures, EPA is quite ineffective. Hence, buccal graft repair seems like the best option. Grafts are created from the buccal mucosa and used in the repair of strictures. However, even this method has only limited success, with strictures often recurring after some time. However, any method to repair long strictures in a single-stage surgery has high failure rate, and use of buccal grafts are the most effective among them.

 

Staged urethroplasty

For patients that have suffered multiple failed hypospadias, staged urethroplasty is the best chance. There are many considerations to be taken while undergoing staged urethroplasty. For instance, the choice of grafts has to be considered carefully before applying. Removal of urethral plate is another decision that must be taken wisely. In most of the cases, two stages are enough to repair any damage caused by a failed hypospadias operation. It must be noted that most men quit after the first stage itself, considering the second stage of urethroplasty closure as unnecessary.

 

Chordee Repair

Ventral penile curvature is another complication caused by a failed hypospadias surgery, though there are many ways to treat it. The most effective method is to induce an artificial erection. Things get complicated when both chordee and strictures are present in the patient. Removal of the urethral plate itself may seem like the best approach, but it rarely works. Instead, it would be better to perform staged surgeries while dealing with the two complications one-by-one.

 

Urethrocutaneous fistula

Urethrocutaneous fistula is one of the most common complications caused after a failed hypospadias surgery. Like strictures, the treatment depends heavily on the size of the fistula. Smaller fistula could be repaired easily with additional catheter drainage. Longer fistula could be repaired by first excising the fistulous tract, then closing the urethra. Closure of fistula is the most prudent way of repairing it.

 

Conclusion

Hypospadias is a defect that can cause you a lot of inconvenience, or may not cause any discomfort at all but repairs are necessary after a failed hypospadias surgery, preferably as soon as possible.

Hypospadias

WHAT IS HYPOSPADIAS?

Hypospadias is a birth defect in baby boy in which the penis neither works well nor looks normal. It is the defect of the Urethra in the male where the urinary opening (Meatus) is not at the usual location on the head of the penis instead that is on the underside of the penis or below the penis associated with curvature (in few cases) and disfigured skin.

 

HOW IT IS DIAGNOSED?

It is diagnosed on the basis of a physical examination done by a urologist. It is one of the most common birth abnormality in boys, affecting approximately 1 of every 250 new born boys.

 

CAUSES OF HYPOSPADIAS

The exact cause of hypospadias is unknown.  There are many factors believed to be involved in its development. Genetics, the environment and hormones may be factors that influence the development of this structural difference. Sometimes hypospadias is genetic.

PRESENTATION OF HYPOSPADIAS MAY INCLUDE:

  • Opening of the urethra at a location other than the tip of the penis
  • Abnormal splaying during urination
  • Downward curve of the penis (chordee) A condition called chordee is often seen with Hypospadias. Chordee is a downward curve of the penis. The foreskin is often not completely formed on its underside. This result in a “dorsal hood” that leaves the tip of the penis exposed.
  • Hooded appearance of the penis as only the top half of the penis is covered by foreskin

 

 

THE TYPES OF HYPOSPADIAS INCLUDE:

  • Distal or Glanular:  most common form when opening is found near the head of the penis
  • Midshaft:  when opening is found in the middle to the lower shaft of the penis
  • Penoscrotal:  when  opening is found where the penis and scrotum join
  • Perineal: when opening is behind the scrotal sac. These are the most severe forms of hypospadias and are less frequently found.

 

 

 

FAILED HYPOSPADIAS

There are more chances of failure if males with Hypospadias are operated by a routine Urologist. Adults / Children with complications following childhood hypospadias repair can still be re-operated with good success rate if are operated by a reconstructive urologist who has been performing routinely.

 

ADULT HYPOSPADIAS

Adult hypospadias are those Males diagnosed with Hypospadias but has not got it corrected at childhood; they live with hypospadias all their life. Such Men suffer needlessly with a regret that they went through their life ignorant to options.  This is absolutely treatable disorder. They can have a normal appearing and functioning penis. They can pee normally and not spray all over the place. They can have pain free sex.

TREATMENT

The goal of any type of hypospadias surgery is to make a normal, straight penis with a urinary channel that ends at or near the tip. The operation mostly involves 4 steps:

  • straightening the shaft
  • making the urinary channel
  • positioning the meatus in the head of the penis
  • circumcising or reconstructing the foreskin

Hypospadias repair is often done in a 90-minute (for distal) to 3-hour (for proximal) same-day surgery. In some cases the repair is done in stages. These are often proximal cases with severe chordee. The Reconstructive Urologist often wants to straighten the penis before making the urinary channel.

Hypospadias can be fixed in children of any age and even in adults.

A successful repair should last a lifetime. It will also be able to adjust as the penis grows at puberty.

“Surgical correction can be undertaken in early childhood or in later life by a reconstructive urologist”.

 

 

HYPOSPADIAS IF UNTREATED influences a man’s psycho-social status. Affected man often feels like he has got this horrible secret in his pants and if others will find out, they would make fun of him.  Hypospadias leads to shame, aloneness and depression that a guy can feel when he is growing up. One of the reasons for feeling so different is because he needs to sit down to pee unlike other Males.

Parents usually ask the Urologist that their child urinates comfortably and has bowel movements just fine. So why are we having the surgery done if it doesn’t hurt him and he urinates just fine? Simple answer to these parents is Surgery is essential because Hypospadias can cause following problems as he gets older:

1. Irregular urine stream .He would have to pee sitting down his whole life.

2. His penis would look different than other boys.

3. It could potentially create fertility issues. The opening of the penis is not close to the cervix as a result of which the sperm is not in the right place to cause pregnancy.

4. If the penis has chordee (downward curvature of the penis) it becomes very painful, difficult or even impossible to have intercourse as an adult.

POST-OPERATIVE COMPLICATIONS

The complication rate in boys with distal hypospadias repair is less than 1 in 10. Problems happen more often after a proximal correction.

The most common problem after surgery is a hole (“fistula”) forming in another place on the penis. This is from a new path forming from the urethra to the skin. Scars can also form in the channel or the urethral opening. These scars can interfere with passing urine. If your child complains of urine leaking from a second hole or a slow urinary stream after hypospadias repair, he should see his pediatric urologist.

Most complications appear within the first few months after surgery. But fistulas or blocks might not be found for many years. Most problems are easily fixed with surgery after the tissues have healed from the first operation (often at least 6 months).

 

 WHAT IS THE RECOVERY TIME AFTER THE PROCEDURE?

Recovery time is bit longer in patients following Re-do surgery for failed hypospadias repair with respect to the Hypospadias surgery done initially. The patient after Re-do surgery can start peeing normally after 2-3 weeks. It may take 3 months for the penile skin to be healed fully. Urinary catheter is kept for 10-20 days post surgery.

 

 WILL I HAVE NORMAL FEELINGS AFTER HYPOSPADIAS SURGERY?

Yes definitely the patient can have a normal penis provided the surgery is done by a Urologist specialized in Hypospadias Repair. You need to follow the instructions given by the surgeon strictly. Do visit for a follow up after the procedure.

 

HOW LONG DOES THE HYPOSPADIAS SURGERY TAKE TO COMPLETE?

Usually it takes 3-4 hours to operate such cases but it differs from case to case depending upon the complexity of the disease. In few cases need multiple stages 6-8 months apart.

WHAT IS THE SUCCESS RATE OF HYPOSPADIAS REPAIR SURGERY?

Modern anaesthetic techniques, fine instrumentation, sutures, dressing materials, and antibiotics have improved clinical outcomes and have, in most cases, allowed surgical treatment with a single-stage repair within the first year of life on an outpatient basis.

Success Rate at Centre of Urethra and Penile Surgery is 95%.

 

WHY TO CHOOSE CENTRE OF URETHRA AND PENILE SURGERY?

  • At our centre for Urethra and Penile surgery the success rate is high as we use latest techniques to operate. We encourage such patients to get themselves reviewed atleast once in a year.
  • Gautam Banga has successfully operated more than 800 Hypospadias cases in his one decade of experience.
  • High success rate in primary cases
  • Achieved success in failed cases of Hypospadias
  • Gautam Banga is invited by his fellow Urologists as a core-specialty expert in Genito-Urinary reconstruction in various parts of Delhi-NCR.

To know more please contact :

Dr. Gautam Banga

MBBS,MS,M.Ch (Urology)
Urologist, Andrologist and Genito -Urinary Reconstructive Surgeon
Contact no. : 91- 9886624303 | +91-9999062316
Email:- info@urethraandpenilesurgery.com