Channel Title: Pediatric Urology & Hypospadias Channel Channel Description: Email: hypospadiasfoundationindia@gmail.com Pediatric Urology & Hypospadias Channel is an endeavour by Dr A.K.Singal, Pediatric Urologist & Hypospadias Surgeon, Dr Manish Dubey (Urologist) Dr Ashwitha Shenoy (Pediatric Surgeon) to impart education to public, parents and doctors about Pediatric Urological disorders and Hypospadias. Dr Singal practices in Mumbai and Navi Mumbai, India and he cares for children with conditions such as Hypospadias, undescended testis, antenatal hydronephrosis, pelvi-ureteric junction obstruction (PUJ obstruction), vesico-ureteric reflux (VUR), Posterior urethral valves (PUV), bed wetting, urinary infections, kidney cancers, inguinal hernia & hydrocele, phimosis and neuropathic bladder. You can whatsapp us at +919324180553 for a second opinion Appointments: 1. MITR Hospital & Hypospadias Foundation, Kharghar -- +91-6262840940 & 9324180553 2. MGM Hospital Vashi -- +91-22-50666777 <video> Urethral fistula closure repair after hypospadias surgery: Dr A.K.Singal/Dr Ashwitha Shenoy Description: Fistula closure after hypospadias repair is a surgical procedure to correct a complication that can arise from the initial hypospadias repair surgery. Hypospadias is a birth defect where the opening of the urethra (the tube that carries urine from the bladder out of the body) is on the underside of the penis instead of at the tip. Hypospadias repair surgery corrects this abnormality. Sometimes during the process of healing, a fistula can occur between the urethra and the skin of the penis. This can cause urine to leak from the fistula opening. In the presence of a fistula the child or adult will pass urine from the opening at the tip pf the penis and from the fistula sites. Fistula closure is a relatively minor surgery compared to the original hypospadias repair. Doctors typically wait several months after the initial surgery to allow for any inflammation or swelling to subside before performing the fistula closure. There are different techniques used for fistula closure, depending on the size and location of the fistula. The surgeon will discuss the best approach for you. Before the fistula closure, we check the calibre of the urethra beyond the fistula. If the distal urethra is normal without any obstructrion then fistula closure will suffice. If distal urethra is strictured then the entire urethra will need to be replaced which needs to be planned in one or two stages. If you are concerned about a fistula after hypospadias repair, it is important to see a doctor to discuss your options. Early diagnosis and treatment can help to improve the chances of a successful outcome. Hypospadias Foundation located in Kharghar, Navi mumbai, Maharashtra is the topmost centre in india and one of the leading centres in the world for hypospadias treatment. Children and adults not only from India but from all over the world visit and get treated successfully at hypospadias foundation. Over the last 15 years we have been performing more than 200 surgeries per year with complication rate of less than 5%. Our expertise in this area has helped us achieve the success in this field. Dr A K Singal and Dr Ashwitha Shenoy are the expert hypospadias surgeons who have dedicated their life in treating children and adults with hypospadias. Their expertise in this area has helped us achieve excellent outcomes in adults and children with hypospadias. </video> <video> Getting good results in Redo hypospadias with Oral mucosa graft repair- Dr A K Singal/Dr Shenoy Description: Oral mucosa repair is mostly used in redo hypospadias or failed hypospadias cases. Sometimes, after multiple hypospadias surgeries the native prepucial skin is unavailable for further repairs. In these cases, we can use oral mucosa graft. The inner lining of mouth such as lips and cheek is a different type of skin and is called oral mucosa. Oral mucosa doesn’t grow hair, is used to remaining wet and heals very fast and well. The graft is harvested from the cheek or lip or from both depending on the length of the graft required. Once the graft is fixed on the penis, it must gain new blood supply from local area in next few days. Hence, we use a tight dressing to make sure that the graft stays fixed for first 7 days. We also leave a catheter to drain urine, we let it drain into a double diaper preferably. After 7 days, we remove the dressing and catheter mostly in the clinic but in some cases minor anesthesia may be needed. After that care of the graft area becomes very important for next few weeks The area from where the graft is harvested, whether it is the lip or inner cheek- is left raw, and no stitch is put. For post-operative care of the mouth, we use a pain killer anesthetic gel for a few days. Then we start an oral steroid gel for a few weeks along with mouth/lip stretching exercises twice a day. There can be minor bleed from mouth or the lip after graft harvest but is mostly self-limiting. Other immediate complication though rare is infection of the graft. If the graft becomes infected, then there is a chance of graft loss. Late complication which we really worry about is the graft contracture, in such cases further graft augmentation may be required. This happens in less than 10% of the cases at our center due to experience across hundreds of cases and good post operative care. Sometimes the graft stays firm inspite of steroid massage. In these cases, urethroplasty becomes difficult and we may have to replace the graft partially or entirely. The graft healing goes through various stages and finally the graft becomes soft in 6 months, it becomes elastic and stretchable just like lip and cheek. That’s the time when we take up the patient for stage 2 repair. Sometimes graft takes longer time to become soft, in such cases we may have to wait even up to one year before we recommend stage 2 repair. After stage 2 repair, we typically keep the patient in hospital for 1-2 nights post-surgery. Dressing is removed after 7 days in children and 5 days in adults. Stage 2 healing takes anywhere between 10-14 days for children and 21-28 days for adults. So that’s the length we like to keep a catheter in and continue bladder antispasmodics, pain killers and a mild antibiotic. Since post pubertal children and adults have slow healing, we also place a suprapubic catheter for such patients for extra safety. After removal of catheter the child or adult should be able to pass urine in a single straight wide stream from the tip of new urethra, that’s how we know that the surgery has been successful. In less than 10% of cases, there may be a minor leakage. Fortunately, what we have seen in oral graft cases is that 90% of these tend to close in first few months. In the other 10% we may need to close the fistula after 6 months. We at hypospadias foundation, Navi mumbai, India do more than 250 surgeries every year for hypospadias and almost 50% of these are redo surgeries where previous surgeries have failed at other centers. In some of these cases oral mucosa repair is the only technique which can give a long-term good result. Typically, at our center we do almost 50 oral mucosa graft surgeries every year. Hypospadias foundation is located at MITR Hospital in Kharghar, Navi Mumbai in the state of Maharashtra. Dr A K Singal is an expert and one of the best hypospadias surgeons in India with experience in pediatric and adult hypospadias. He is a gifted surgeon and his expertise in this area has helped us achieve excellent outcomes in primary and failed hypospadias in children as well as adults. </video> <video> Laparoscopic pyeloplasty in a child for PUJ obstruction secondary to crossing vessel Description: PUJ obstruction, or pelviureteric junction obstruction, can occur in children and is the most common cause of pediatric hydronephrosis (swelling of the kidney). It occurs about 1 in 1,500 to 2,000 newborns. 40% of time there can be bilateral obstruction. Most of the times this is congenital in nature. Sometimes, a blood vessel near the PUJ can be abnormally positioned and compress the junction, obstructing the flow of urine.Most of the infants and young children remain asymptomatic. Older children may present with symptoms such as abdominal or flank pain, palpable lump in the abdomen or recurrent urinary tract infections (UTIs). Prenatal ultrasounds can detect hydronephrosis before birth, but the actual diagnosis can happen only after birth. Ultrasound KUB and a nuclear renal scan are the tests done to diagnose PUJ obstruction. Rarely CT KUB may be required in older children with suspicion of PUJ due to crossing vessel. Not all PUJ obstructions require immediate treatment. Doctors will monitor the severity and its impact on the kidney function. If the blockage is severe and impacting the kidney’s health, surgery in the form of pyeloplasty is done to relieve the obstruction. In case of PUJ obstruction due to crossing vessel, the blood vessels must be carefully preserved during the surgery. Damaging these vessels may cause loss of lower pole of the kidney. If you have any concerns about your child having PUJ obstruction, consult your pediatrician or a pediatric urologist for a proper evaluation. Early diagnosis and early treatment are the key to save the kidney. For further queries, do consult us or visit us at MITR hospital, Kharghar, Navi Mumbai </video> <video> Top 7 questions about Hypospadias Treatment & Repair Surgery asked by parents Description: Here are certain questions and answers about hypospadias treatment and repair surgery. 1. Why is surgery needed for Hypospadias and is it needed for all hypospadias? Surgery is required in hypospadias to correct the chordee, to create a urinary passage and bring the opening to the tip of the penis. Our intent is to have the final cosmetic result where the penis is straight, the opening is at the tip and child passes urine in single straight stream without any pain. Final cosmetic would be like a circumcised penis. In most of the hypospadias cases, surgery helps in functional and cosmetic outcomes and child will grow normally without any psychological impact of having an abnormal penis. In some cases of minor hypospadias, where the meatus is on the glans and there is no chordee, we may decide to not do a surgery. But such cases are rare. 2. Is Anaesthesia safe during hypospadias surgery? Hypospadias surgeries are done under general anaesthesia. Right from dosage of medications to managing airway is very different in children when compared to adults. Hence, at Hypospadias Foundation we have 3 skilled pediatric anesthesia experts who give anesthesia for hypospadias surgery. In addition to general anaesthesia, at our centre we also prefer to give an injection in the lower spine (caudal anaesthesia) which gives good pain relief to children for 12 hours after the surgery. Pain relief is our priority after surgery so that children can be comfortable after surgery. 3. Will there be lot of Pain after hypospadias surgery? With modern anesthesia and good painkiller medications, we have seen children being very comfortable and having an excellent pain relief at our centre post hypospadias surgery. Common surgical pain is easily managed with pain killer medicines. Children can develop pain in the post operative period either due to bladder spasms or erections. Bladder spasms are controlled by a tablet oxybutynin. Penile erections at night or early in the morning can also cause pain. Such pain is generally not severe and can be managed well by the painkillers which we prescribe. However, penis continues to be sensitive for 2-3 weeks after the hypospadias repair surgery. 4. What are the Complications of Hypospadias Surgery? The risk of complications following surgery at our centre is less than 5%. The most common complications which we encounter are fistula formation, diverticulum formation, meatal stenosis, or rarely wound infection. An additional surgery may be required in some of these complications. A minor complication is not the end of the world. In majority of these cases even after a suboptimal result a good outcome can be achieved in expert hands. 5. Does hypospadias cause Infertility? Most of the children or adults will have normal fertility once they have achieved good outcomes with hypospadias surgery. Only in children with undescended testis or a Disorder of sex development there are chances of infertility.That being said, Uncorrected hypospadias or a failed Hypospadias surgery can cause male infertility in hypospadias due to various reasons. It may be due to abnormal location of the meatus, diverticulum, stricture or presence of chordee. The severity of hypospadias and the success of surgical repair will ultimately decide if they will be able to father a child. Hence in men with hypospadias suffering from infertility they need to get in touch with a hypospadias surgeon because getting the hypospadias repaired will increase their chances of having children. 6. What are the Risk of hypospadias in my next child or in future generation? Most of the hypospadias cases are isolated cases with no genetic basis. The risk of hypospadias in future generations is influenced by several factors such as genetic and environmental factors. If the father has hypospadias, then the risk of developing hypospadias in future generations will be 5-6% Similarly, if first child has hypospadias, the risk in second boy is almost 5%. 7. What is the Cost of surgery and insurance coverage/cashless/mediclaim? Hypospadias being a penis birth defect is classified as an external birth defect which can be easily diagnosed as soon as the baby is born. Hence, if parents take an insurance policy after the baby is born, hypospadias surgery treatment is not covered by most of the insurance companies in India atleast while in USA, UK it is covered under insurance benefits. The situation is different for some of the corporate insurance group policy holders. Some big corporates issue very employee friendly mediclaim policies which cover all medical and surgical treatments for the employees and their families. Such mediclaim policies may cover all pre-existing as well as birth defects for their employees and hence hypospadias repair procedure may be covered by the insurance companies in these circumstances. </video> <video> Dorsal chordee correction in an adult by 16 dot plication technique Description: Isolated dorsal curvature of the penis is extremely rare. It is easily recognized in boys with epispadias and extrosphy. It may or may not be associated with hypospadias. The reason for dorsal curvature in these children is secondary to the development of corpora and an open urethral plate. Sometimes there may be dorsal curvature of the penis secondary to circumcision due to shortage of dorsal skin. Minor cases of dorsal chordee does not require any intervention. In severe cases of dorsal chordee, surgical correction will be required. The above video is of a patient with severe dorsal chordee who underwent correction of dorsal chordee by 16 dot plication technique. At Hypospadias Foundation, we get adults and children from all over the world in search of treatment for hypospadias. We provide support and information for children, adults, and their families affected by hypospadias. Dr Singal and Dr Shenoy are deeply devoted to creating awareness and helping patients get the right treatment and best outcomes for hypospadias. Children and adults from more than 25 countries visit Hypospadias Foundation in search of treatment for hypospadias. Dr A K Singal is a highly experienced surgeon and is regarded as the best hypospadias surgeon in India and in the world for treating children and adults with hypospadias. If you are looking for a highly skilled and experienced pediatric urologist and hypospadias surgeon for yourself or your child, then Dr Singal is an excellent choice. Dr Ashwitha Shenoy is an expert pediatric surgeon with a special interest in pediatric urology and hypospadias. Dr Singal and Dr Shenoy’s collaboration allows them to offer advanced surgical techniques and comprehensive care for patients. </video> <video> Laparoscopic Surgery for relieving Kidney Swelling in a child due to PUJ Obstruction: Expert opinion Description: Laparoscopic Surgery for relieving Kidney Swelling in a child due to PUJ Obstruction: Expert opinion Pelviureteric junction obstruction is narrowing at the junction of the renal pelvis of kidney and the ureter which causes restriction of flow of urine from the kidney into the ureter. The block is usually partial hence some amount of urine may drain across the junction. This swelling seen as dilatation of renal pelvis increases over time. Over a period the functioning part of the kidney called cortex, or parenchyma may start decreasing leading to a decrease in the function of the kidney if not treated at early stage. Most of PUJ Obstructions are diagnosed during the antenatal scans done in pregnancy. If the antenatal scans show any hydronephrosis i.e swelling in the pelvis of the kidney without any swelling of the ureter or bladder, then PUJ Obstruction is the most likely diagnosis. This swelling can be seen as early as 18-20 weeks of pregnancy. A postnatal ultrasound at 7-10 days after birth is mandatory to assess the degree of hydronephrosis. If the postnatal scan shows hydronephrosis of more than 15mm then we do a nuclear renal scan which will confirm if there is an obstruction, and this renal scan also give us an idea about the relative function of the kidney. If missed in the antenatal period, children may present with a lump in the abdomen, or flank pain, urinary tract infections etc which are usually seen in older children with PUJO. Not all cases of antenatally diagnosed PUJ obstruction require surgery. A developing child has a very high urine output and hence in almost 70% of cases swelling may decrease after birth and surgery may not be needed. But it is critical to do follow up ultrasound and if needed renal scans to assess if kidney is not getting damaged and the swelling is decreasing. Surgery is required in PUJ obstruction if a. There is progressive increase in the HDN with thinning of the renal parenchyma on ultrasound. b. Renal scan shows decrease in the renal function with obstructed drainage. c. Child has symptoms such as flank pain, palpable lump in the abdomen, repeated urine infections or stone formation. The surgery to correct PUJO is called pyeloplasty. In this surgery we remove the abnormal blocked area and suture the normal area of the renal pelvis to the ureter. This establishes a good urine flow across the PUJ and has a very high success rate. During the surgery a thin tube which is called as DJ stent is placed across this junction with one end of the stent in the kidney and the other end in the urinary bladder. This DJ stent is typically removed 6-12 weeks later by a day care endoscopic procedure. Till 20 years back, all the children used to undergo open surgery for PUJ Obstruction. With miniature scopes, well trained pediatric urologists, majority of children with PUJ obstruction undergo laparoscopic pyeloplasty. At our centre we have been doing laparoscopic pyeloplasty for children as young as 4 months for last 18 years. For laparoscopic pyeloplasty, we make three small incisions of 5 mm and 3mm and place ports to see everything and perform surgery. The entire surgery is done through these three ports. The procedure is same as in open surgery but via long instruments which are inserted inside through the ports. The advantage of laparoscopic pyeloplasty are minimal post operative pain, early recovery and small scar. In the immediate post operative period some children may develop urine leak from the surgery site and that’s why we leave a drain for first 2-3 days. Drain is removed when the leak stops. There rarely may be bleeding which stops by itself in first week or wound infection which can be managed with by local wound care and antibiotics. The success rate of pyeloplasty at our centre is 98%. The first follow up after surgery is done after 8-12 weeks for DJ stent removal. Ultrasound is done one month after DJ stent removal and a renal EC scan is done 3 months after DJ stent removal. If ultrasound shows improvement, then one ultrasound is done at 6 months after the follow up ultrasound and yearly ultrasounds thereafter. EC scan is repeated only once after surgery. 2% children may develop recurrent obstruction and may need redo pyeloplasty. Laparoscopic pyeloplasty is feasible in PUJ obstruction in children beyond 3 months of age. Laparoscopic pyeloplasty is possible only if the surgeon has expertise in laparoscopy and good intra-abdomen suturing skills because it has a longer learning curve compared to open pyeloplasty. Once mastered it is better than open surgery because of good cosmetic results and less morbidity. Some doctors say that the swelling disappears once the baby urinates after delivery. This is not true. The swelling does not disappear once baby passes urine. Hence if antenatal scan showed any hydronephrosis please do visit a pediatric urologist and get your child checked at the earliest. </video> <video> Vesicoureteric reflux in children - Symptoms, diagnosis and management Description: Urine is formed in the kidney, and it drains from the kidney into the ureter and then the bladder. Normally there is natural valve at the junction of ureter and bladder. In case of vesicoureteric reflux, this valve doesn’t work. A large number of children with VUR may remain asymptomatic. The most common symptom in VUR is recurrent urinary tract infections. Neonates and infants with urinary tract infection may become very sick requiring hospitalization. Older children may have additional urinary symptoms such as difficulty in passing urine, burning urination, increased frequency of urination etc. When a child presents with symptoms of urinary tract infection, a urine routine microscopy, urine culture and ultrasound KUB is done. Antibiotics are started immediately while confirmatory tests are planned once UTI is fully clear. Micturating cystourethrogram (MCU) is the gold standard for diagnosis and assessing the severity of VUR. In children with VUR, the contrast material refluxes or goes up into the ureter or the kidney. It is an invasive test and must be done at a centre where there is pediatric urology expertise. Nuclear DMSA scan is a must in VUR to know the function of the kidney and to identify possible areas of renal injury which are shown as scars on DMSA. The first line of management for VUR in children is always medical. Regular follow up appointments are scheduled for ultrasound. Children are started on an antibiotic prophylaxis which is given every night. If the child gets urinary tract infections inspite of the above measures, then surgical management is recommended. In infant boys with high grade VUR, we also advise circumcision which significantly reduces the risk of urinary infections. With proper medical management, less than 10% of children should need a surgical intervention. In low grade reflux, endoscopic or cystoscopic injection of a bulking agent such as deflux or dexell is a good option. In this procedure, a substance in injected in the bladder at the region where the ureter opens into the bladder. This will prevent the reflux of urine. The success rate of this procedure is 70-80% in carefully selected cases. In high grade reflux cases, the valve needs to be reconstructed by doing a ureteric reimplantation surgery. The success rate of this procedure is more than 95%. If your child has urinary infections starting from young age, VUR must be ruled out else there may be chances of renal damage. If your child has VUR, please see a pediatric urologist or a pediatric nephrologist or write to us(pediatricurology.in) for any further information. </video> <video> Adult post hypospadias stricture repair in single stage using oral graft: Hypospadias Foundation Description: Hypospadias is commonly diagnosed in childhood, but adults also present with hypospadias because either they were never operated in childhood, or they have complications after multiple hypospadias surgeries in childhood. The common presentation with which they present with are recurrent urinary tract infection, difficulty in passing urine with poor stream, difficult sexual intercourse, or infertility. The common findings which we find in adults post failed hypospadias repair are hairy urethra, residual chordee, urethral diverticulum or urethral stricture. Most of the adults with these complications will need a redo surgery. This redo surgery can be either in single stage or two stages. In more than 95% of the surgeries, we need to use oral mucosa graft while reconstructing the urethra. It is used either as an inlay graft or in staged repair. In the presence of long segment unhealthy urethra, we may need to plan a staged repair. The unhealthy urethra must be removed, and oral mucosa graft should be placed in first stage and in second stage the urethra is reconstructed from the graft placed in stage 1. The second stage is planned when the oral graft over the penis becomes soft like lip and can be easily rolled to form a urethra. The duration between the two stages is somewhere between 6-9 months. If there is short segment of urethra which needs to be replaced, then it can be done in single stage by placing an oral mucosa inlay graft. The healing in adults after hypospadias repair is slow as compared to children hence per urethral catheter is kept for a longer time which is around 21-28 days. Suprapubic cystostomy is done in every adult undergoing hypospadias urethroplasty. This helps in decreasing the stress on our urethroplasty suture line which in turn contributes to better healing. </video> <video> Single stage redo hypospadias repair with lateral onlay flap- Dr A.K.Singal/Dr Ashwitha Shenoy Description: Hypospadias is usually diagnosed after birth in the neonatal period by a pediatrician. Once diagnosed, referral to a pediatric urologist is necessary to plan surgery at the right age. As per the guidelines the best age for hypospadias surgery is between 9 to 18 months. Hypospadias Surgery is planned in single or two stages depending on the severity of hypospadias. After chordee correction, usually there is insufficient skin on the underside of the penis to reconstruct the urethra hence extra tissues either in the form of prepuce (in primary) and residual prepuce or oral mucosa graft (in redo cases) are used for urethroplasty. The main aim of Hypospadias repair is to achieve a forward straight urine stream and normal or near normal looking penile appearance after hypospadias surgery. The important factors to be considered during any hypospadias repair are glans groove, urethral plate and chordee. Each patient with hypospadias is unique and these factors help us to decide the type of repair possible in them. After hypospadias repair, dehiscence like in the present case happens in less than 5% of the cases. A redo surgery may be required to complete the repair. In specialized centers, single stage onlay flap repair can be done for such failed cases. Onlay flaps can only be made after a careful evaluation. There should be no or minor chordee and secondly enough residual prepuce available. Flaps should be well vascularized otherwise there is risk of flap necrosis. Hypospadias Foundation is located at MITR hospital in Kharghar, Navi Mumbai in the state of Maharashtra. Every year we get children and adults from all around the country and the world in search of a cure for hypospadias. We have successfully treated thousands of children and adults with hypospadiash. Our dedication, determination, and perseverance in the field of hypospadias has helped us achieve excellent outcomes. Dr A K Singal is a top and expert surgeon who has dedicated his life in treating children and adults with hypospadias. His expertise in this area has helped us achieve excellent outcomes in adults and children with hypospadias. Dr Ashwitha Shenoy is an expert pediatric surgeon with special interest in pediatric urology and hypospadias. Both Dr Singal and Dr Shenoy work together to give best results for hypospadias surgery in India for both children and adults. </video> <video> Single stage Redo hypospadias repair in an adult with Oral Mucosa Graft Description: Hypospadias is commonly diagnosed in childhood, but adults also present with hypospadias because either they were never operated in childhood, or they have complications after multiple hypospadias surgeries in childhood. The common complaints which they present with are poor stream, urinary tract infections, spraying of urine, difficult sexual intercourse, or infertility. The common findings which we find in adults post failed hypospadias repair are hairy urethra, residual chordee, urethral diverticulum or urethral stricture. Most of the adults with these complications will need a redo surgery in either single or multiple stages. In more than 95% of the surgeries, we need to use oral mucosa graft while reconstructing the urethra. It is used either as an inlay graft or in staged repair. Cystoscopy is performed initially before planning the hypospadias repair. In cystoscopy, we can identify the presence of diverticulum, stricture, hair in the urethra or presence of diverticulum at the prostatic utricle. Depending on the the length of unhealthy urethra, surgery is planned in single or two stages. Use of oral mucosa graft is an excellent option in adults undergoing redo repair. Healing in adults is slow as compared to children. Per urethral catheter is kept in situ for minimum 21 days after urethroplasty in adults. Suprapubic catheter is also done in every adult after urethroplasty at our centre. About Hypospadias foundation At hypospadias foundation, we get adults and children from all over the world in search of treatment for hypospadias. We provide support and information for children, adults and their families affected by hypospadias. Dr Singal and Dr Shenoy are deeply devoted to creating awareness and helping patients get the right treatment for hypospadias be it primary, redo or adult hypospadias. Children and adults from more than 25 countries visit our hypospadias foundation in search for cure and are cured of hypospadias. Dr A K Singal is a highly experienced surgeon and regarded as the best hypospadias surgeon in India and in the world. He has dedicated his life towards treating children and adults with hypospadias. His expertise in this area has helped us achieve excellent outcomes in adults and children with hypospadias. Dr Ashwitha Shenoy is an expert pediatric surgeon with special interest in pediatric urology and hypospadias. Both Dr Singal and Dr Shenoy work together to give best results for hypospadias surgery in India for both children and adults. </video> <video> Scrotal hypospadias with severe chordee -Staged Repair surgery using dermal graft and flaps Description: Scrotal hypospadias is a condition where the urinary opening is in the scrotal region. It is a severe type of hypospadias. Majority of children with severe hypospadias have associated chordee (abnormal bending of the penis). Chordee correction (straightening of the penis) is the first and an important step during hypospadias repair. It ensures that the penis is straight which is essential for normal function and appearance. In this case, the chordee was severe hence ventral lengthening procedure in the form of dermal graft was done to correct the chordee. When this chordee is severe the hypospadias is repaired in two stages. Incomplete correction of chordee can lead to residual chordee which often worsens at puberty. Following chordee correction, the prepuce was divided in the midline, rotated and sutured on the ventral aspect of the penis, a procedure known as Byars flap. This step is essential because this rotated prepuce is used to create the urethral passage in second stage repair i.e urethroplasty. Staged repair is a better option in hypospadias with moderate to severe chordee for better long-term outcome. The minimum duration between the two stages is 6 months. Post-surgery children are able to pass urine in a single straight stream with less than 5% risk of future complications in expert hands. Dr A K Singal is an expert and top hypospadias surgeon in India and the world. He is a gifted surgeon and his expertise in this area has helped us achieve excellent outcomes in primary and failed hypospadias in children as well as adults. Dr Ashwitha Shenoy is an expert pediatric surgeon with special interest in hypospadias and pediatric urology. Both Dr Singal and Dr Shenoy work together to give best results for hypospadias surgery in India for both children and adults. </video> <video> Laparoscopic surgery for adnexal cyst torsion in a young girl - Dr A.K Singal/Dr Ashwitha Shenoy Description: Adnexal cysts in children Adnexal cysts in children, particularly ovarian cysts, are relatively common and often benign. They are fluid-filled sacs that develop on or near the ovaries. While they can cause discomfort or pain in some cases, they usually resolve on their own without treatment. Adnexal cysts can be ovarian or paratubal cysts. Ovarian cysts are more common. Paratubal cysts develop near the fallopian tubes and are less common in children. Small adnexal cysts in children cause no symptoms and are discovered during a routine ultrasound. Large adnexal cyst may cause symptoms such as lower abdominal pain or discomfort, pelvic pain, lower abdominal mass and in older children it can cause changes in menstrual cycle. Ultrasound is the investigation of choice in adnexal cyst. This is done to visualize the ovaries, confirm the presence of cyst and to determine the size of the cyst. In case of doubt, CECT abdomen and pelvis is done. Blood tests such as alpha fetoprotein and b-hCG should be done in a case of adnexal cyst. In most cases, small, asymptomatic cysts are monitored with regular ultrasounds. They often resolve on their own within a few months. Analgesics like acetaminophen or ibuprofen can help manage discomfort. Surgery may be needed to remove a large, complex cyst or one that is causing significant symptoms or complications. During surgery care should be taken to avoid injury to the ovary and fallopian tube. Complete removal of the cyst wall should be done. It's crucial to consult a doctor if your child experiences any persistent abdominal pain or other concerning symptoms. Early diagnosis and appropriate management can help prevent complications. </video> <video> Top 7 things which Pediatrician must know about Hypospadias- Dr A.K.Singal/Dr Ashwitha Shenoy Description: Top 7 things which Paediatrician must know about Hypospadias After the child is born the pediatrician will usually examine the child from head to toe for any external anomalies. In a normal male neonate, glans is covered by the foreskin and prepuce is complete. Hypospadias is very evident in a newborn due to ventrally incomplete prepuce, visible glans and a urinary opening on the underside of penis. The pediatrician should also check the presence of testis in the scrotum. If the testis is not palpable in the scrotum in presence of hypospadias, further evaluation for a disorder of sex development (DSD) should be carried out. Some of the children with severe hypospadias may also have a very small phallus which may look like a clitoris. If the child has Hypospadias with undescended testis, severe hypospadias, or hypospadias with a microphallus, then we need evaluation for DSD. A thorough evaluation is necessary before planning the definitive management in DSD. The treatment plan is formulated only once we arrive at a diagnosis. In addition to a pediatric urologist opinion, the child is also referred to a pediatric endocrinologist for hormonal evaluation. Typical tests for DSD include Karyotyping, hormonal tests and maybe an MRI scan of the pelvis to check for female internal genitalia. If the child has isolated hypospadias, without suspicion of DSD, it is wise to refer the parents to visit a pediatric urologist before 6 months of age. Typical evaluation and counselling are best done at this age. This also gives time to the family to prepare for surgery. In children with suspected DSD, referral to a pediatric urologist should be done in the newborn age itself. The pediatric urologist will check the position of the meatus, size of penis, assess the degree of chordee and the location of testis. In children who are born full term, have a good weight, no major associated anomalies and are thriving well, the best age for hypospadias surgery is around 9-12 months but definitely before 18 months of age. We recommend surgery between 9-12 months of age because it is easier to manage the child in the post-operative period, healing is excellent in infants. The second-best age will be from 3-5 years of age. In children who are born pre-term, have failure to thrive or associated anomalies, it is better to operate between 3-5 years of age when other issues are sorted out. This gives us the best chance to give safe anesthesia and ensure good recovery. Surgery for hypospadias is done under general anesthesia along with caudal analgesia. The type of surgery for hypospadias depends upon the degree of hypospadias and degree of chordee. Chordee correction or the straightening of penis remains the single most important step in hypospadias repair. In cases of mid, distal and proximal penile hypospadias, if the chordee is less than 30-degree, surgery can be done in a single stage. If the chordee is more than 30 degrees, then we need to do staged repair. The minimum gap between the two stages is 6 months. Most of the children with severe hypospadias such as penoscrotal, scrotal and perineal hypospadias, need a staged repair for long term good outcomes. The success rate of hypospadias surgery at our center is above 95%. The most common complications which we encounter are fistula formation, diverticulum formation, meatal stenosis or rarely wound infection, an additional surgery may be required in some of these complications. Successful results in hypospadias are a culmination of experience and a correct choice of technique. Even after this a small number of children may have a complication but that’s not the end of the world. In most of these cases even after a suboptimal result a good outcome can be achieved in expert hands with second surgery. Most of the children or adults will have normal fertility once they have achieved good outcomes with hypospadias surgery. Only in children with undescended testis or a Disorder of sex development there are chances of infertility. Uncorrected hypospadias or a failed Hypospadias surgery can cause male infertility due to various reasons. It may be due to abnormal location of the meatus, diverticulum, stricture or presence of chordee. The altered or narrow opening of the urethra can cause problems in ejaculation, hence causing infertility. Presence of chordee can make sexual intercourse difficult or painful. The severity of hypospadias and the success of surgical repair will ultimately decide fertility. Hence it is important that an expert surgeon performs the hypospadias surgery, and a long-term follow-up is maintained. In cases of hypospadias, proper evaluation, preparation and a sound surgical technique is important for good outcomes. It is also important that first surgery is done at a centre where there is a large amount of experience and dedication to genital surgeries in children. Fortunately, science and advances in surgery have made it possible to have excellent outcomes. </video> <video> Urinary Stone disease in children: Diagnosis and management Description: Kidney and urinary stones were unheard of in children in the past. In the last two decades, the incidence of kidney and urinary stones has increased in children. The reason for increased urinary stones in children is due to imbalance of minerals and pH of urine leading to initial crystallization and then stone formation. High intake of junk foods and processed foods, poor water intake, obesity and high salt diet are some of the risk factors for stone formation. In some children the stone is formed due to metabolic causes such as hypercalciuria, hyperoxaluria, hyperuricemia or hypocitraturia. The symptoms which occur in children are pain in the back or in the flank, painful urination, difficulty in passing urine, increased frequency of urination, blood in the urine or urinary tract infection. Rarely kidney stones may form secondary to a congenital obstruction to a urine flow. Whenever there is suspicion of kidney or urinary stones in children an ultrasound is done to confirm the presence of stone, number of stones, stone anywhere else in the tract other than the kidney and any associated hydronephrosis. A plain Xray can tell us a radiodensity of the stone. If the stone is strongly suspected but not seen on Ultrasound, then we elect to do a CT scan to see a small stone particularly in the ureters. Once kidney stone is confirmed, blood and urine tests called Metabolic work up is done. The management of urinary stones in children can be medical or surgical. The management of kidneys stones can be medical or surgical. For a small stone less than 6mm in kidney, we wait and watch. Once it moves into ureter, it causes pain and symptoms but even these do not need surgery as first line of treatment. In case of smaller stones in ureter up to 6mm in size, medical management is sufficient to clear the stone. This consists of hydration, antispasmodics, alpha blockers and antibiotics while we wait for the stone to pass spontaneously. Alpha blockers are started in case of ureteric stones which dilates and relaxes the ureter in turn aiding in expulsion of the stone. Sometimes medical management can fail for small stones, and stone doesn’t move for 2-3 weeks or causes extreme pain, in such cases surgery may be needed. In children with larger stones, impacted stones and increased stone burden surgery will be mostly required to clear the stones. Endoscopic surgery is possible in children due to advent of pediatric cystoscopes, ureterorenoscopes and nephroscopes. For stones in kidney, we do an endoscopic procedure called Mini Perc or Mini PCNL. When the stone is the ureter, we do a procedure called URS or ureterorenoscopy. At MITR Hospital Pediatric Urology department, we have a very small 4.5 sized URS scope which can be passed into ureter of even a 1-year-old child in most cases and then stone can be broken with Holmium laser into small pieces and a stent is left. This stent is removed after 3-4 weeks by endoscopic procedure. Follow up is a must for any child who has been diagnosed with stone disease even after complete clearance. Pediatric stones are notorious for recurrence. Once the stone has been cleared by a pediatric urologist, a follow-up with a pediatric nephrologist is a must to prevent recurrence. This includes a full blood and urine checkup and regular follow-up with an ultrasound. A child has a full life ahead of him or her, we must make sure that the stones do not recur. Few years ago, pediatric kidney stones were cleared by an open surgery by a large incision on the flank. With the recent technology, the stone can be cleared by endoscopic method without any skin incision and even if required it will be a small incision of less than 1cm. If your child has a kidney or a urinary stone, please consult a pediatric urologist or write to us for a second opinion. </video> <video> Diagnosis and Management of undescended testis Description: Testis is normally located in the scrotum. When the testis is absent in the scrotum it is called undescended testis. On clinical examination, if the testis is felt in the inguinal region or in the groin, it is called palpable undescended testis. When the testis is not palpable it is called non palpable undescended testis. The testis can be inside the abdomen or outside in the groin region which can be determined by clinical examination in the OPD. In the newborn period the pediatrician checks for the testis in the scrotum immediately after birth. If the testis is absent in the scrotum, then your pediatrician will refer you to a specialist pediatric urologist. The specialist pediatric urologist will examine and confirm the same. Ultrasound can be done to identify the location of the testis, but it is not always necessary. The treatment options are based on various factors such as location of testis and age of the child. After birth we wait for the first three months for testis to drop down spontaneously into the scrotum. If it does not, then we plan the surgery after 6 months of age. If the testis is palpable in the groin, then it will an open surgery and the testis is brought down into the scrotum and fixed into the scrotum. If the testis is inside the abdomen, then it must be done laparoscopically. In a small baby of less than one year of age, 90% of the time we will be able to bring the testis into the scrotum in one stage. If the testis is higher up, then we may have to bring the testis into the scrotum in two stages. The duration between the stages will be 4-5 months. In a bigger child there is 50% chance that it may be a single or two stage procedure. If your child has undescended testis, then do visit a specialized pediatric urologist at the earliest so that the surgery can be planned at the right age and right time. After surgery the risk of complications are less than 5%. The complications which can arise are immediate or late. Immediate complications can be scrotal swelling (scrotal edema) which will subside in 2 to 3 weeks. Late complications will be testis ascending back into the groin. At ~ 1 year of age the damage to the testis starts hence the undescended testis must be operated by 1 year of age. If the surgery is delayed, then there is a risk of testicular cancer in the undescended testicle in adulthood. The risk of infertility in one sided undescended testis is same as the general population. However, in bilateral undescended testis ~50% have shown decreased sperm density hence the risk of infertility is higher in cases of bilateral undescended testis. If your child has undescended testis, then do visit a pediatric urologist at the earliest. You can visit pediatric urology department at MITR hospital for an expert opinion for your child. </video>

Contacts and Links

Description

Email: hypospadiasfoundationindia@gmail.com
Pediatric Urology & Hypospadias Channel is an endeavour by Dr A.K.Singal, Pediatric Urologist & Hypospadias Surgeon, Dr Manish Dubey (Urologist) Dr Ashwitha Shenoy (Pediatric Surgeon) to impart education to public, parents and doctors about Pediatric Urological disorders and Hypospadias. Dr Singal practices in Mumbai and Navi Mumbai, India and he cares for children with conditions such as Hypospadias, undescended testis, antenatal hydronephrosis, pelvi-ureteric junction obstruction (PUJ obstruction), vesico-ureteric reflux (VUR), Posterior urethral valves (PUV), bed wetting, urinary infections, kidney cancers, inguinal hernia & hydrocele, phimosis and neuropathic bladder.
You can whatsapp us at +919324180553 for a second opinion
Appointments:
1. MITR Hospital & Hypospadias Foundation, Kharghar -- +91-6262840940 & 9324180553
2. MGM Hospital Vashi -- +91-22-50666777

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