‘Hidden’ Hypospadias Failures: Residual Chordee
Recently I saw an 18-year-old boy who underwent 3 prior operations for hypospadias in another state. He told me that he came to me for closure of the fistula (an abnormal opening on the undersurface of the penis from which urine comes out, which typically occurs as a complication of hypospadias surgery). His father too shared the same concern. On examining the previous surgery records, I understood that he had mid-penile hypospadias (urinary opening in the middle of the penile shaft) to begin with, for which he underwent 3 prior operations. He is now passing urine from an opening close to the tip of the penis, but there was an additional hole (fistula) in the middle of the penile shaft. When I examined the boy (actually a young man), his penis seemed to be curved downwards (typically called ventral chordee). When I enquired further, he told me that his penis was indeed bent downwards; this became worse and more prominent, especially during erections (which is typical of chordee), and cause him great discomfort, fear and concern regarding his future sexual life. When I asked him why he did not reveal this initially, he said ‘I thought that is how my penis is, and nothing can be done about it’!! After hearing this, the father was also deeply concerned and worried. I informed them that this ‘chordee’ was a more important and complex problem than the fistula, and assured them that it could be corrected and the penis could be straightened by surgery. This was going to be more challenging than the closure of the fistula. The boy subsequently underwent successful re-operation by us to correct the chordee and close the fistula too!
This case illustrates an important ‘hidden’ complication of hypospadias surgery, recurrent or residual chordee. In our experience, over 80% of adolescents presenting with failed hypospadias had significant residual chordee. In many cases, although the patients and parents knew that the penis was bent downwards, they thought that it was their fate and that nothing could be done about it. Instead, they were concerned about simple problems like fistula (fistula is not exactly simple, but residual chordee is a worse problem)! It is very important that the Hypospadiologist(specialist in hypospadias surgery) thoroughly examines the patient with failed hypospadias before deciding on the course of surgical treatment. In most cases, it is better to examine the patient physically and not rely too much on online consultations.
One of the most difficult complications of hypospadias surgery in terms of treatment is residual or recurrent chordee. If the initial chordee correction is done well, the possibility of re-occurrence of chordee should be about 5% only (because of the growth of the penis at puberty sometimes recurrent chordee can occur). The problem is if the chordee is incompletely corrected at the time of initial surgery; in such a situation, recurrent chordee is almost always noticed during or after puberty (it may be noticed before but is better seen and felt by the patient once he is older). There are many reasons why chordee is incompletely corrected at the time of initial surgery:
- The surgeon may not be experienced enough to assess the chordee correctly. Correct assessment and complete correction of chordee requires a lot of experience. A surgeon who performs only a few hypospadias cases in his/her practice may never get the required experience or expertise.
- The surgeon may want to complete the hypospadias surgery in a single operation (single-stage repair) even in a case of severe hypospadias. Sometimes the parents may insist and force the surgeon to complete the repair of severe hypospadias in a single operation. Even if the parents insist on single-stage repair of severe hypospadias, a good surgeon will never submit to their force. In our own research recently published in an international journal, we have shown that in cases of severe hypospadias, 2-stage repair gives far better results with better success and fewer complications when compared to a single-stage repair. In my previous blogs, I have written about both single-stage and 2-stage hypospadias repairs; the readers can read those blogs for more information.
The correction of residual chordee, although difficult, can nevertheless be done with good results in the hands of the expert Hypospadiologist. If the residual chordee is <300, the chordee correction may be possible in a single-stage. However, when the residual chordee is >300 (which is the case in many failed hypospadias cases), it may require 2 stages (including a skin graft or oral mucosal graft) to correct it. Again, this decision is best made by the expert Hypospadiologist.
Thus, the job of the parents is to take the child to the most experienced and expert surgeon in hypospadias surgery and let the surgeon decide what is best for their child. The parents should ask the surgeon relevant questions like how many hypospadias operations the surgeon does, what are his/her results, can the claims of the surgeon be verified (like any scientific papers or books on hypospadias written by the surgeon), etc. Readers are encouraged to read my previous blog on ‘How to choose the right surgeon for your child’s hypospadias?’. Otherwise, major complications can occur and it may be very painful for the child and the parents to have multiple re-operations. Remember: Prevention of complications is better than dealing with them after they occur!!