HomeFor DoctorsFor ParentsFor AdultsEmotionalProf. HadidiPublicationsContactImprint

Questions regarding surgery for hypospadias correction:

13. Does Professor Hadidi personally operate on  public patients as well or only private patients?

Professor Hadidi operates personally all hypospadias patients. Patients with private insurance are operated on in Emma Hospital. Patients with public insurance are operated on in Offenbach Hospital.

Professor Hadidi consults and examines all patients personally before surgery and follow up all his patients personally.


14. What is the procedure for patients outside Germany, who would like Professor Hadidi to operate on our son?

Please send an e-mail to Professor Hadidi with all details like child´s name and birth date, your address and telephone-number. There are two possibilities:

  • To have the operation done in Emma Klinik in Germany.
  • To have the operation done in your country. Professor Hadidi travels few times every year to several countries including Spain, Greece, Hungary, Romania and Egypt when there are enough patients to justify the travel.

15. When should the hypospadias-operation be performed?

Recent studies showed that the ideal time for hypospadias correction is between 3 and 18 months as the penis grows less than 1 cm during the first 3 - 4 years

Ideal age for hypospadias surgery


16. Should we do any tests before surgery

In Grades I, II, IIIa,  when the child has no complaints or problems, there is no need to perform any tests before surgery. However, some hospitals prefer to do routine blood check, blood coagulation tests, urine analysis or ultrasound on the kidney and bladder.

In Grade IIIb and Grade IV blood check, blood coagulation tests, urine analysis or ultrasound on the kidney and bladder is recommended according to the doctor evaluation of each individual child.


17. When should we do chromosomal analysis (tests)?

In glanular and distal hypospadias (Grade I, II, III a) with both testes in the scrotum, this is not necessary.

In perineal hypospadias (Grade III b, Grade IV) or when hypospadias is associated with undescended testis and in patients suspected of having disorders of sexual development (DSD).chromosomal analysis is  important to accurately identify the gender of the child.


18. 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 cream 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 recommend to use pre-operative hormonal therapy as a routine 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 Disorders of Sexual Development (DSD) or when the phallus is very small.


19. Is vaccination a contra-indication for surgery?

Vaccination makes the immune system weaker than normal for about a month. Therefore, it is recommended that the last vaccination should be at least one month before surgery and the next vaccination should be at least one month after surgery.


20. If my son develops running nose, diarrhea, cough, fever before surgery, does this affect the operation?

If the child has running nose only without fever or chest infection, the operation is performed as planned in our centre. Diarrhea in our centre does not postpone the operation. However, each hospital has different protocol of management.


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

  • Children with glanular or distal hypospadias usually he can go home between 1 - 5 (average 3) 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 (grade III a)  usually have one transurethral catheter for 7 days and the child can go home on day 8th.
  • Children with proximal hypospadias associated with deep chordee (Grade III b) usually have 2 catheters, one transurethral catheter for 7 days and another  catheter 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 catheter does not come out.
  • Children with perineal hypospadias usually require two stage urethroplasty. In the first operation, the surgeon corrects the chordee (penile curvature) and prepares the glans for the urethroplasty. The hospital stay is 3-5 days. In the second stage, urethroplasty is performed to the tip of the penis and the hospital stay is usually 8-14 days.

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

The aim after hypospadias surgery is to fix the penis and not the child.

This means that the child can move around as soon as he is fully awake from anesthesia. He can sleep on his abdomen and lead a normal life. However care must be taken to protect the genital area and to avoid unplanned removal of the catheter


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

In glanular and distal forms (Grade I,II) the dressing is usually removed 1-2 days after the operation. In proximal forms (Grade III, IV) the dressing is usually removed 7 days after the operation.


24. How long should the catheter remain in penis?

Different surgeons have different protocols:

Prof. Hadidi removes the catheter from the urethra within the first 2 days in Garde I, II hypospadias and after 7 days after proximal hypospadias (Grade III, IV) or in complicated hyposapdias.


25. Will my son receive medications after surgery?

  • Grade I, II receive antibiotics and local ointment for one week after surgery.
  • Grade III, IV receive antibiotics and local ointment for two weeks after surgery.

26. How can I clean my son after surgery? When can he take a shower?

You can clean immediately after surgery with a wet towel. When you clean the penis this should be longitudinally along the wound and not across.

  •  your son can take a shower one week after surgery for distal hypospadias.
  • your son can take a shower two weeks after surgery for proximal hypospadias

27. When can my son sit in the bath tub or swim or play sport?

The idea is that we need to keep the wound clean and dry for proper healing and to avoid infection.

The wound takes one month to heal by 70 %. That is why we try to avoid swimming or bathing or sport for one month after surgery.


28. When can my son go back to kindergarden?

Ideally, we should wait for one month. However, if we can avoid trauma to the penis before, your son may go to the kindergarden earlier with special precautions.


29. Can my son use pampers after surgery? Are there any precautions?

Our standard protocol is to use 2 pampers immediately after surgery and this should continue for a month after surgery. The idea is that pampers protect the penis from trauma. However, for one week after surgery, we need to change the pampers every two hours when the child is awake. When he is asleep, we should not wake him up to change the pampers.


30. Are there any precautions when my son travel by car, How about the seat belt?

Our aim is to avoid trauma to the penis and the genital area for one month after surgery. Therefore, in addition to the two pampers your son is wearing, we recommend to put twofloded pampers between the seat belt and the pampers on the penis.


31. Which techniques are preferred for hypospadias-repair?

More than 300 operative techniques have been described for the correction of hypospadias. The surgeon should use the technique that brings in his own hand the best results.

The following algorithm summarizes Professor Hadidi´s protocol for different forms of hypospadias:

Prof. Hadidi`s Techniques for Hypospadias repair


32. I have noticed that the Tubularised Incised Plate (TIP)  technique (sometimes known also as "Snodgrass-Technique") is NOT in the algorithm of operations performed in the hypospadias center, why?

About one third of patients referred to the Hypospadias Centre had a failed TIP procedure. The concept of the TIP procedure results in leaving a large raw surface in the reconstructed urethra. This raw surface usually contracts during healing resulting in a very narrow urethra and persistent fistula. Occasionally, the whole wound disrupts completely and urine comes out from the original opening. The condition becomes more complicated when the surgeon during the TIP procedure has excised the forskin. This makes the job of correction more difficult as there is no excess skin available to reconstruct the narrow urethra.

TIP complication: pin point meatus TIP Complication: more urine from fistula

Pin point meatus after TIP 

more urine from fistula         

TIP complication: partial deciscence TIP Complication: complete dehiscence

partial dehiscence                   

complete dehiscence


33. What is the preferred technique for glanular hypospadias (Grade I)?

When the child has glanular hypospadias without chordee and the urethra is long enough to reach the tip of the glans, Professor Hadidi prefers to use the Double-Y-Glanuloplasty (DYG) technique. In this technique, the urethra is mobilized and brought to the tip of the penis. In other words, there is no new urethra reconstruction needed and therefore, the success rate is more than 98 %.

DYG Technique for glanular Hypospadias

glanular hypospadias pics pre-inter-post op


34. What is the preferred technique for distal hypospadias (Grade II)?

When the urethral opening is in the outer half of the penis without deep chordee, Professor Hadidi prefers to use the Slit- Like Adjusted Mathieu (SLAM) technique. In this technique, a skin flap from the penile skin is turned upward to form the lower surface of the new  urethra. The new urethra can be made as wide as the original urethra and the success rate of this technique in experienced hands is more than 95 %. Complications that include fistula, stenosis, wound dehiscence are less than 5%.

The "Slit-Like Adjusted Mathieu (SLAM)" for distal  Hypospadias:

SLAM-Technique after Hadidi for Hypospadias Repair

Photos distal hypospadias pre-intra-post


35. What is the preferred technique for proximal Hypospadias without deep chordee (Grade III a)?

When the urethral opening is in the inner half of the penis without deep chordee, professor Hadidi prefers to use the lateral Based Onlay (LABO) technique. In this technique, a skin flap from the penile skin as well as the prepuce is turned around to form the lower surface of the new urethra. The new urethra can be made as wide as the original urethra. The technique has particular value in patients with small glans and the success rate of this technique in experienced hands is more than 93%. Complications that include fistula, stenosis, wound dehiscence are less than 7%.

The "Lateral Based Onlay (LABO) -Technique" for proximal Hypospadias without deep chordee:

Proximal Hypospadias - drawings

Photos proximal Hypospadias Grade III a


36. What is the preferred technique for Proximal Hypospadias with deep chordee (Grade IIIb)?

When the urethral opening is in the inner half of the penis with deep chordee, Professor Hadidi prefers to use the lateral Based (LAB) technique. In this technique, the hypoplastic tissues that prevents the penis from being straight are excised and skin flap from the penile skin as well as the prepuce is turned used to reconstruct the whole new urethra. The new urethra can be made as wide as the original urethra. The success rate of this technique in experienced hands is more than 85 %. Complications that include fistula, stenosis, wound dehiscence and diverticulum are less than 15 %.

The lateral Based (LAB) flap for proximal Hypospadias with deep chordee:

Proximal Hypospadias Grade III b - Drawings

Proximal Hypospadias Grade III b - Photos


37. What is the preferred technique for Perineal Hypospadias (Grade IV)?

When the urethral opening lies in the perineum and the scrotum is usually divided, sometime one or both testes are not in the scrotum, Professor Hadidi prefers to perform a two stage urethral reconstruction. In the first operation, the chordee is excised, the testes when high are brought down to the scrotum and the glans is opened widely and covered with preputial skin as a preparation for urethroplasty. In the second operation, urethroplasty is made to the tip of the glans. The success rate of this technique in experienced hands is more than 85 %. Complications that include fistula, stenosis, wound dehiscence and diverticulum  are less than 15 %.

The two stage repair for perineal Hypospadias with deep chordee:

Perineal Hypospadias drawings

 

Perineal Hypospadias before operation

  Perineal Hypospadias after 1st operation

Perineal Hypospadias 2 yrs after 2nd operation

before operation

after the first operation

2 yrs after 2nd operation


38. What is chordee? Are there different types? Does this affect surgery? If the penis is curved, how would it be corrected, is this necessary and when?

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.

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 Professor Hadidi experience, 50 % of the patients with proximal hypospadias have no chordee or superficial chordee that can be corrected by skin mobilization. The other 50% of proximal hypospadias (Grade IIIb) have deep curvature that has to be corrected by excision of the short hypoplastic tissue that is usually present distal to the urethral opening.

Almost all patients with perineal hypospadias (Grade IV) have deep chordee that has to be corrected in the first stage operation.

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

The  SUPERFICIAL type is usually present in 20% of distal hypospadias and in about 50% 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).

The 2nd type of chordee is the DEEP  chordee. It is usually present in about 50% 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.).

Superficial Chordee, drawing

Deep Chordee, drawing

Superficial chordee

Deep Chordee


39. 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 (dorsal plication). 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 (correcting one deformity below by creating another deformity above).

In addition, many adults complain of short penis and painful erection following the Nesbit procedure or dorsal plication.

Nesbit Procedure - drawing

When a child has hypospadias associated with deep chordee (penile curvature), the first step is to correct the chordee. There are two approaches for this; Possibility a: is to excise all the hypoplastic tissues that prevents the penis from being striaght. With this approach, the penis is more straight and longer than before surgery. Possibility b; is to shorten the upper surface of the penis. With this apporach, the penis is straight but shorter than before surgery. In addition, many adults complain of pain with erection as the penile body needs space for expansion and is restricted above by the sutures and below by the hypoplastic tissue.


40. What happens to the foreskin at the end of the operation?

There are 3 possiblities regarding the remaining foreskin after urethral reconstruction; 1) to leave it as it is and perform either forskin reconstruction or circumcision after 6 months.2) to do circumcision at the end of urethral reconstruction. 3) to do foreskin reconstruction at the end of urethral reconstruction.

Professor Hadidi prefers to leave the foreskin as it is and deal with it according to the wish of the parents 6 months after urethral reconstruction.This will be discussed in more details at a later question.


41. Why you do NOT recommend and do NOT perform the TIP technique although many surgeons are still doing it?

About one third of patients referred to the Hypospadias Centre had a failed TIP procedure. The concept of the TIP procedure results in leaving a large raw surface in the reconstructed urethra. This raw surface usually contracts during healing resulting in a very narrow urethra and persistent fistula. Occasionally, the whole wound disrupts completely and urine comes out from the original opening. The condition becomes more complicated when the surgeon during the TIP procedure has excised the forskin. This makes the job of correction more difficult as there is no excess skin available to reconstruct the narrow urethra.

TIP complication: pin point meatus TIP Complication: more urine from fistula

Pin point meatus after TIP 

more urine from fistula         

TIP complication: partial deciscence TIP Complication: complete dehiscence

.


42. After I leave the hospital, when should I be worried and call the surgeon?

We tell the parents not to look at the penis for one month after surgery until the swelling disappear and the wound has healed by 70%.

However, the mother should contact the surgeon when the child has severe pain or difficulty to pass urine or can not passs urine for more than 6 hours.

43. After I leave the hospital, when should I go to my routine pediatrician?

Normally, there is no need to go to your pediatrician regarding the operation. If there is real worry, you need to contact your surgeon.

However, if your son develops fever or other complaints not related to the operation, you should go to your pediatrician as is usually the case..


44. If my son develops fever after hospital discharge, is this related to the hypospadias operation?

If your son has no (or little) pain when passing urine and the wound is not very swollen and red, it is almost certain that the fever has nothing to do with the hypospadias operation and you should contact your pediatrician to exclude flu, chest infection, teething…etc.


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

Professor Hadidi uses very fine absorbable sutures (finer than the human hair) and they dissolve spontaneously between 1-3 months after surgery and there is no need to remove them. 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.


46. I have noticed that my son penis became red 3-4 weeks after hospital discharge and he has some pain when he passess urine is this normal?

As mentioned above, the sutures start to dissolve about one month after surgery. They dissolve by having a chemical reaction. When this occurs, the penis may become red, swollen and small yellow “pustules” may appear. This is all normal and will disappear within a week without leaving a trace.

Small pustules during the absorption of sutures 3-4 weeks after surgery:

Pustules sometimes appearing in the first month after surgery, no worry


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

It takes one month for the wound to heal by 70 % and 6 months to heal by 100 %. This is why any further surgery should be planned 6 months after the last surgery.

This means that we should avoid any trauma to the penis for one month, use 2 pampers of sport protection for one month. Also: swimming, bathing, sport should be postponed for one month after surgery

After one month, the wound is stable and the child can lead a completely normal life (please note, that for ad

However, complete healing takes about 6 months after surgery.


48. Will the new urethra grow normally with the penis as my son grows?

The new urethra is made of your son own skin and fascia with normal blood vessels. It will grow normally as your son grows.


49. When should post operative examinations take place and for how long?

Our standard protocol is that the parents send an e-mail one month after surgery to report how is the healing of the operation. The first routine post.operative examination is 3 month after surgery by the operating surgeon (Professor Hadidi). We recommend to maintain regular follow up after 1, then 2, then every 3 years until puberty.


next page ...


[Home][For Parents][for parents 2][for parents 3]

copyright Prof. Hadidi 2012
www.hypospadias-surgery.com