#Redo #Surgery #Failed #Hypospadias #repair #Key #points #success #Hypospadias #Foundation #India
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Posted by Hypospadias Foundation
Email: hypospadiasfoundationindia@gmail.com
Whatsapp: +919821261448
1. What is failed hypospadias?
a. A hypospadias surgery is defined as successful when the child is able to stand and pass urine comfortably in single straight thick urine stream in one go. Erections are straight and the cosmetic result is very close to a normal circumcised penis.
2. What are the common types of failure in hypospadias?
a. Fistula is the most common complication of hypospadias surgery. Fistula is suspected when there is leakage of urine from the some point other than the new meatus. If the fistula is small and the new urethra is wide, the fistula may heal by itself but most of them do not heal and require further surgery.
b. Stricture/ stenosis: The new opening can become narrow in few cases and this is called stricture or stenosis. Early stenosis can be managed by calibration (insertion of tube through the meatus) or a minor surgery in the form of meatotomy if the stenosis is severe. Sometimes the meatus may look narrow but if the stream is good, there is no need for any surgery or intervention.
c. Dehiscence: Breakdown of repair is called dehiscence. It may be partial only for the head of penis- called glans dehiscence while complete dehiscence is less common. Usual causes include infection or poor technique. Complete dehiscence may require redosurgery while minor forms of dehiscence may be left alone if the stream is straight and good with acceptable cosmetic result.
d. Diverticulum: Swelling of the new urethra is called diverticulum formation and may present as dribbling, poor stream or with infections. Most of the diverticulum require corrective surgery.
e. Recurrent chordee: Chordee correction is the first step and the most important step in all hypospadias repairs. In cases where the chordee has not been corrected fully, curvature may re-appear. Rarely, it can be due to excess scarring as well. Recurrent chordee should be corrected and remains a challenging problem to solve.
f. Suboptimal cosmetic result- Cosmetic result is an essential component of hypospadias repair. The penis may have skin tags, abnormal meatus shape or scarring. Minor cosmetic aberrations will become better with time, but major ones will require corrective surgery.
3. What are the causes for failure?
a. Pre-operative preparation- size, hormonal analysis, no other comorbid infections, pink of health
b. Improper selection of technique- Hypospadias repair can be done by various techniques, but it is advisable for the surgeon to use one which is comfortable with after evaluating the anatomy.
c. Under trained surgical team- complex cases to be done only by team doing more than 50 cases a year, results improve with focus and volumes, teams always better
d. Post- operative care- Post operative care involves adequate pain relief, antibiotics which is given intravenous for initial 24-48 hours and changed to oral antibiotics at discharge. First follow-up in the immediate post-operative period will be for dressing change at 7-10 days after surgery in children and 4th day in adults followed by second follow up for catheter removal which depends on the healing of the operated site.
4. What is the treatment for failed hypospadias?
a. Redo surgery depending on the complications
b. Sometimes it may be better to do staged repair if the anatomy has become unsuitable, prepuce is used up, there is scarring, stricture, paucity of tissues, recurrent chordee. In select circumstances, the surgeon may choose to do a single stage surgery for cases such as fistula or diverticulum.
c. Buccal Mucosa Graft – In some cases where the local anatomy has scarcity of tissues, we advise buccal or oral mucosa graft to be taken from lip or cheek to be used for reconstruction of penis. The mucosa of mouth has good healing properties and in expert hands has extremely good results even in cases where multiple previous surgeries have failed.
5. What’s the success rate for failed hypospadias at hypospadias foundation
a. Every year we get 150-200 children and adults for treatment at hypospadias foundation and almost 50% of these are referred after surgery somewhere else. Some of these have undergone 5 or more surgeries elsewhere, infact we can recall atleast 5 patients who had more than 7 surgeries elsewhere.
b. Every case of failed hypospadias is very unique and tissues get altered because of previous surgeries and healing becomes slow. Hence choosing the right technique is important. Do not hesitate to choose a staged repair if that will give better results.
c. We are committed to helping these children and adults and we work diligently as a team for these cases. Using proper techniques, newer tissues like oral mucosa and tunical flaps, we have been able to achieve a very good success rate of more than 95% in finally giving a good result to even failed hypospadias.
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