Residual or Recurrent Chordee after Hypospadias Surgery

Recently, we published a very important paper in the prestigious international journal “Pediatric Surgery International”. In that paper, through a meta-analysis of previously published data, we assessed the various techniques of correction of chordee in hypospadias, and the success of each technique. We reached some important conclusions

1. Residual or recurrent chordee is common after previous failed hypospadias operations
2. The technique of chordee correction is important
3. Some commonly used techniques of chordee correction have a higher failure rate than others
4. Many surgeons do not objectively measure chordee during the surgery but rely on subjective estimation; this leads to high failure rate of the surgery

There are several techniques of chordee correction. The best technique involves 2 essential components

1. Objective assessment of chordee at each stage of the operation
2. Step-wise protocol during surgery to ensure complete chordee correction

In my practice as an expert in Hypospadias surgery, I see many failed cases of hypospadias where the initial operations have been done elsewhere. Such cases come to us not only from both Telangana and Andhra Pradesh, but from across the country. We observed that more than 75% of these failed cases have significant chordee. In some cases, it is because the chordee was not totally corrected at the time of the previous surgery (residual chordee), while in some other cases, the chordee is because of faulty technique from previous surgery, resulting in recurrent chordee. In many cases, there may be a combination of both these factors.

So, when any child comes to us with a failed hypospadias operation, our first step during the reoperation is to assess whether there is chordee. Any chordee requires adequate correction before we proceed with further steps of surgery. The correction of residual/recurrent chordee is a very important and difficult step in these re-operations. Many times, we may have to remove all the scarred tissues of the previous operation and start the reconstruction as if it is a fresh case. In cases with chordee <20-30⁰, we might be able to correct it by a technique of dorsal plication (again there are many technical variations of this procedure). However, if the chordee is severe (>30⁰), more complex techniques have to be employed to correct the chordee. In many such cases, due to the paucity of good quality skin on the penis, we may need to go for a 2-stage reoperation with the use of Oral Mucosal Graft (OMG). In this technique, the skin (more specifically, called the mucosa) from inside the oral cavity (lip or cheek) would be taken and grafted on the penis after the correction of chordee. In the second stage, this mucosa is used to reconstruct the urethra. These are complex operations which should be performed only by the best experts in hypospadias surgery. However, in the hands of experts, good results of upto 90% success can be expected.

Thus, I again stress the same important principle of hypospadias surgery. The first operation on the child has to be performed by the best expert in the field. It is important for the parents to do some research and identify the best expert in hypospadias surgery. If the first operation is not done properly, subsequent reoperations are more complex, and the child as well as the parents will be subjected to great mental trauma due to multiple operations. Unfortunately, most parents initially consider hypospadias as a ‘minor’ operation!! They get their child operated by a locally available surgeon, without verifying whether that surgeon has expertise in hypospadias surgery or not. I have written in my previous blog many practical tips for the parents to help them identify the expert surgeon for their child’s hypospadias surgery. If the parents follow these steps, they can avoid many complications and thus avoid multiple operations in their child.