Frequently Asked Questions

Questions regarding Surgery

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Questions regarding surgery:
  1. Which techniques are preferred for hypospadias-repair?
  2. If the penis is curved, how would it be corrected and is this necessary?
  3. How long does my child have to stay in hospital?
  4. Does my child has to be bed ridden or can he move around after the hypospadias-operation?
  5. How long should the dressing remain on the wound?
  6. How long should the catheder remain in penis?
  7. What is meant by Chordee?
  8. What is "Nesbit-Procedure" and when should it be performed?
  9. What are the possible complications and how often do they occur?
  10. What happens with the sutures and threads after surgery? Do they need to be removed?
  11. When should post operative examinations take place?
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7. Is an operation necessary?

If the child has a glanular hypospadias (grade 1) the operation may not be necessary from the functional point of view. This means that he may not have problems with urination or with erections and sexual function later on in life. However this mild form of hypospadias may affect the child psychologically as the penis will not look normal and may result in wetting his cloths during urination or psychological problems. Many adults with unoperated glanular hypospadias do not wish that their partners realize that they have abnormally looking penis.

If the child has distal (grade 2) or proximal (grade 3) hypospadias the operation is important to ensure adequate functions of the penis in the form of urination, erection and sexual function later on in life. Apart from the repair, children with hypospadias may have a very narrow opening that needs to be widened or dilated in order to avoid back pressure and infection of the bladder and kidneys.


8. Will my son become "normal" after hypospadias-operation?

Yes, in children with glanular (grade1), distal (grade 2) and the majority of proximal (grade 3) hypospadias, if the operation is done by an experienced surgeon. However in a small percentage of patients (especially in proximal forms) complications may occur that may impair the appearance or the function of the penis.


9. Will he function as a "normal" man later on when he grows up?

In the majority of cases, yes.


10. Should my son receive hormonal treatment before the hypospadias-operation?

Glanular and distal hypospadias and majority of proximal hypospadias do not need pre-operative hormonal treatment. Some surgeons prefer to use pre-operative hormonal treatment in the form of creme or injections in severe forms of proximal hypospadias. The drawback with hormonal treatment is that it does not affect the penis only but affects the whole body including bone growth and the effect of hormons on the penis is temporary (1 month after therapy).

Prof. Hadidi does not like to use pre-operative hormonal therapy because of its adverse effect on the body in general and because it alters the tissues of the penis and increases the chances of bleeding. However pre-operative hormonal therapy may be helpful in patients with intersex, where the phallus is very small.


11. Should we do chromosomal analysis (tests)?

In glanular and distal hypospadias with both testis in the scrotum, this is not necessary. However in severe forms of proximal hypospadias or patients with intersex chromosomal tests are important to accurately identify the gender of the child.


12. When should the hypospadias-operation be performed?

Recent studies showed that the ideal time for hypospadias correction is between 3 and 15 months as the penis grows less than 1 cm during the first 3 - 4 years.


13. Which techniques are preferred for hypospadias-repair?

More than three hundred operations have been described for the treatment of hypospadias.

In general the popular techniques for glanular and distal hypospadias include the "Mathieu-" and "Tubularized Incised Plate Technique". For proximal hypospadias popular techniques include "lateral based flap", "onlay, "preputial island flap", "tubularized incised plate technique" and "two-stage-repair".

The Tubularized Incised Plate repair (Snodgrass 1994) is based on the assumption that midline incision into the urethral plate may widen it sufficiently for urethroplasty without stricture. Many centres report excellent results with this technique. There are two important criteria to achieve good results: the urethral plate should not be less than 1 cm wide and there should be no distal deep chordee. The technique has gained popularity because it is easily performed, with few complications and results in a slit like meatus. However, Professor Hadidi does not recommend the TIP technique because it is associated with much higher incidence of urethra stenosis and fistula that reaches 35 % in distal hypospadias and upto 66 % in proximal hypospadias.

For glanular hypospadias with mobile meatus, Prof. Hadidi prefers to use the "Inverted Y technique". For hypospadias without chordee, he prefers to use Inverted Y Thiersch or the "Y-V glanuloplasty modified Mathieu" approach. The author has adopted the "lateral-based flap technique"for proximal hypospadias with deep chordee.


 

Inv. Y Glanuloplasty


Inv. Y Tubularised Plate Technique


Tubularised Plate Technique


 Y-V modified Mathieu Technique

"Y-V modified Mathieu Technique"


Lateral Based Flap Technique

"Lateral Based Flap Technique"


14. If the penis is curved, how would it be corrected and is this necessary?

Glanular hypospadias usually has no curvature at all.

80 % of distal hypospadias have no curvature as well. The remaining 20 % have curvature due to shortening of the skin that is usually corrected during the operation of hypospadias.

According to the experience of the author 80 % of the patients with proximal hypospadias have deep curvature that has to be corrected by excision of the fibrous unhealthy tissue that is usually present distal to the urethral opening.


15. How long does my child have to stay in hospital?

If the patient has glanular or distal hypospadias usually he can go home between 1 - 5 days after the operation depending on the age of the patient, the family circumstances and the degree of swelling after the surgery.

Children with proximal hypospadias need to have a catheder through the abdominal wall into the bladder for about 2 weeks. The child may stay in the hospital up to 2 weeks but may go home earlier if the mother can look after the child and ensure that the catheder does not come out.


16. Does my child has to be bed ridden or can he move around after the hypospadias-operation?

Usually the child is allowed to sit and move around and lead a normal life 24 hours after the operation (however care must be taken to protect the genital area).

However in proximal forms of hypospadias extra care must be taken to avoid slippage of the catheter outside the bladder.


17. How long should the dressing remain on the wound?

Usually the dressing is removed within 2 days after surgery.

"A dry wound is a clean wound". If a dressing is left on the wound and is getting wet, this increases the chances of infection.


18. How long should the catheter remain in penis?

Prof. Hadidi does not prefer to leave catheters in the penis for more than 2 days after operation because of his belief that the presence of catheter causes irritation and inflammation of the urethra and increases the chances of complications. In cases of glanular and distal hypospadias the child is allowed to pass urine through the new urethra within 2 days after surgery depending on the age of the child. In cases with proximal hypospadias the author inserts a catheter into the bladder through the abdominal wall and the catheter remains in place for 10 - 14 days.


19. What is meant by chordee?

Chordee means downward curvature of the penis. The curvature is usually most obvious during erection, but resistance to straightening is often apparent in the flaccid state as well. Chordee is usually but not always associated with hypospadias.

Essentially, there two main types of chordee associated with hypospadias. Superficial and deep chordee.

The superficial SUPERFICIAL types is usually present in distal hypospadias and in about 20% of proximal hypospadias. It is important to notice that in superficial chordee, the tethering bands and the penile curvarture are present proximal to the hypospadias meatus (Fig). 

Chordee superficial

The other common type of chordee is the DEEP  chordee. It is usually present in about 80% of proximal hypospadias and about 10 % of distal hypospadias. It is important to notice that in deep chordee, the hard, rigid tethering bands and the penile curvarture are present distal  to the hypospadias meatus (Fig.)

Chordee deep


20. What is "Nesbit-Procedure" and when should it be performed?

The "Nesbit-Procedure" is a procedure that tries to correct ventral curvature of the penis by shortening the upper surface of the penis. This usually results in further shortening of the penis.

Prof. Hadidi does not recommend this approach for the correction of the penile curvature, as it results in shortening an already short penis.


21. What are the possible complications and how often do they occur?

The incidence of complications in glanular and distal hypospadias is less than 5 % if the operation is performed by an experienced surgeon.

The incidence of complications after proximal hypospadias is up to 20 % depending on the experience of the surgeon.

The commonest complication after hypospadias-surgery is fistula, which means that the urine comes from another opening in addition to the meatus. Other complications include infection, disruption of repair, meatal stenosis, loss of the flap, bleeding and disfigurement.

As more surgeons are performing now the TIP procedure, the incidence of urethral stenosis has increased.

 

Fistula

 


22. What happens with the sutures and threads after surgery? Do they need to be removed?

The sutures Prof. Hadidi uses in the hypospadias repair are absorbable (usually within a month). However, some of the threads may take longer than that in some patients. This is normal and should not alarm the parents or the patient. It is important not to try to pull them out, as this may interfere with the healing. Rarely the sutures can leave some tracks in the skin and this is what we call "suture tracks" This does not interfere with the function and usually the appearance of the penis. If it occurs and annoys the patient or the parents they can be excised during the foreskin reconstruction or circumcision.


23. How long does it take for the hypospadias repair to heal and what are the precautions?

The hypospadias repair would heal by about 70 % in one month, for complete healing of the repair this may take up to 6 months (this is one reason why Prof. Hadidi does not recommend any operations during the first 6 months after hypospadias surgery). It would be very important to avoid sport activity which may cause trauma to the penis during the first month of the surgery as well as swimming or bycicle riding.


24. When should post operative examinations take place?

The first post operative examination should take place after 3 months.  Prof. Hadidi recommends further examinations  6 months after the operation. The post operative examinations should be done by the surgeon who performed the surgery. However if you wish to have an appointment earlier we are happy to arrange this as well.

Later on a follow-up-examination every year is recommended until after puberty.


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