Chapter X

Circumcision and Hypospadias

The halachik discussion in this article is, when is it permitted, required, and forbidden to undergo a urethroplasty or hypospadias and chordee repair, and are there circumstances when it is permitted to postpone a ritual circumcision for the benefit of a urethroplasty. Hypospadias refers to someone being born with a urinal orifice (meatus) along the underbelly of the penis and not at the apex of the glans penis. A chordee is a forward curvature of the penis towards the feet. A chordee condition is usually accompanied with a hypospadias. In more serious hypospadias cases the surgeon will demand that the mohel leave the foreskin or most of it, this means that he cannot perform a circumcision. At the time of operation the mohel is still not allowed to complete the circumcision, but the surgeon removes the foreskin by attaching it to the body of the penis and at that point it loses its identity as a foreskin and becomes part of the body. This removal is not the ceremony of circumcision and therefore the mohel did not perform the mitzvah. Consequently, the question is, is it permitted not to perform a ritual circumcision for the benefit of a urethroplasty.

We thank Dr. K.I. Glassberg, pediatric urologist at Downstate University Hospital, for his cooperation with helping us understand the subject matter. Before I discuss the halacha, I will first give you to the medical background about the subject. The statistics dealing with the success and failure rates and the ability to correct these failures and post operative complications, are based on Dr. K.I. Glassberg's skill as a master surgeon in this field operating on both infants and adults. There are other states and countries with surgeons that report a greater percentage of failures and post operative complications with many incurable. The statistics based on the new procedures are not complete since at the present time there are not that many adults who had undergone these procedures to study. Some articles that have been written on this subject can be found in the Journal of Urology, especially the one by Dr. J.W. Duckett Jr., and in the British Journal of Plastic Surgery.

Hypospadias repairs can be explained as a urethroplasty that is usually done in two stages in one operation. If a chordee needs to be corrected it is corrected during the hypospadias repair.

 

Part Ia. Chordee Correction

A chordee is a penis curved foward towards the feet. There are different degrees of chordee. Some of the milder cases including non-hypospadias cases are simply caused by the foreskin pulling on the glans penis. This bends it or curves it towards the ventral side (towards the feet). Some of these cases can be corrected by a mohel during circumcision.

More severe chordees with ventral curvature of the penis, are caused by the penile skin on the ventral side, either because it is not elastic enough, or that it is abnormally short. It is corrected by freeing the skin and adding to it new skin.

 

Part Ib. Correcting the Position of the Hypospadias Meatus

The term hypospadias meatus refers to the urinary orifice at birth. In more severe cases when the hypospadias meatus is further from the glans penis the correction is done by artificially extending the urethra (the urinary canal), from its position at birth to near the tip of the glans. In less serious cases where the hypospadias meatus is in the zone of the glans, a magpi procedure may be selected to reposition the meatus to near the glans without creating a new urethral canal from skin.

When artificially extending the urethra, the preferred method is the method usually used. The procedure is to roll a thin layer of skin that was sectioned from the urethral plate, (the undersurface of the penis that is located between the hypospadias meatus and the tip of the glans), over a rubber or plastic tube. There are cases when there is no urethral plate. When the penis is attached to the scrotum and the glans comes right out of the scrotum, then only foreskin mucosa may be used to roll the tube. The meatus is stretched forward, and the urethral skin canal is inserted into the natural urethra as an extended urethral skin canal. This layer of skin or mucosa is left attached at one end to the penis to keep the blood flowing to the skin keeping it alive. By keeping the blood circulating the skin has a much better chance for its outer layer to attach itself to the inner urethra and eventually it will be nourished by the blood supply from the penis.

The procedure of inserting the rolled skin tube is done by making an incision from the ventral side of the penis (the side facing the feet which is opposite the dorsal side facing the head) from the hypospadias meatus to near the tip of the glans. This tube is then inserted in the slit, and one end is attached to the hypospadias meatus and the other end extends to near the tip of the glans. After several days the rubber or plastic tube is removed leaving a newly formed urethral extension that has been crafted from his own skin.

An alternative to using skin from the urethral plate is to use the mucosa of the foreskin. Another alternative to the mucosa of the foreskin is buccal mucosa or mucosa taken from the inner cheek. The disadvantage of this technique is that the mucosa is not attached to the body and it initially is left without a blood supply unless it succeeds at a later date to become attached to the inner urethra and it will then be nourished by the blood supply from the penis. This disadvantage is a cause of an increase in the fistula type of post operative complications. A fistula is an orifice that develops leading from the urethral skin canal to the outside. Mucosa can also be used to cover the exposed portion of the urethral plate and lesions of the operation, however, foreskin is the choice to cover the exposed portion of the urethral plate. If buccal mucosa, or detached foreskin, or detached foreskin mucosa, is used there will be an increase of fistula type of post operative complications developing somewhere on the outer layer of the penis that covers the urethral skin canal and leading into the urethral skin canal.

During the operation the mucosa of the foreskin and the foreskin are removed, therefore, if a follow up operation is needed the buccal mucosa is used. The foreskin is rarely used for rolling a tube because it is a relatively tough skin that often grows hair and it is more difficult for it to successfully attach to the inner urethra.

One of the determining factors if and how the hypospadias repairs is done is the position of the hypospadias meatus. A textbook article written by Dr. John W. Duckett, gives three general categories according to the position of the hypospadias meatus. The anterior position ranges from below the tip of the glans penis to just below the corona. The middle position ranges from somewhat below the corona until about the beginning of the scrotum. The posterior position ranges from somewhat below the beginning of the scrotum until below the scrotum. The further the hypospadias meatus is from the tip of the glans penis or the closer it is to the body the longer the urethral skin canal must be and the more skin and mucosa is needed for both the urethral canal and to cover the lesions from the operation. The hypospadias meatus and the post operative fistula are covered with penile skin and the penile skin is sewn, this seals the opening. Afterwards, the area is covered with foreskin or mucosa.

The operation is performed on the ventral side where there is very little foreskin mucosa and foreskin on this side. When more skin is required the choice would be to take more skin from each lateral position (side) as opposed to the dorsal side which is further away from the side of the operation. The lateral positions are (e.g. 3 to 5 o'clock and 7 to 9 o'clock). The available skin can be maximized by splitting the foreskin into skin and mucosa. When foreskin and mucosa foreskin is needed from the dorsal side to be used on the ventral side or the side of the operation the skin is detached leaving some blood vessels attached. This procedure significantly reduces the blood supply to this skin and is the reason for an increase of post operative fistulas.

 

Part II. Covering the Lesions of the Operations

Fifty percent of hypospadias cases are in the anterior zone where a magpi procedure may be done without rolling a tube. The procedure relocates the meatus to near the tip of the glans.

The preferred skin for covering lesions of the operation is foreskin that is left attached to the penis at one side. Foreskin mucosa that is left attached to the penis at one side is second choice. Foreskin mucosa and buccal mucosa not attached to the body is third choice. The undersurface skin of the penis must be replaced if its outer layer was sectioned off for rolling a tube. There are other lesions resulting from the operation that must also be covered. The rules about from where and how to take the foreskin or foreskin mucosa are the same as those described before for rolling a tube.

Another source of skin that should be tried is "Apligraf", from Novartis. This product is a skin grown from cells taken from foreskin. It is used to cover wounds and has several advantages. It is not rejected by the body, and it grows into the wound to be replaced within four to six weeks by the bodies own tissue. It is limited to use on an area that has a vascular or granular tissue bed. This excludes using Apligraf to cover the post operative fistula, but it does not exclude it from covering a fistula repair after sewing the penile skin. Even if this product may not work in all cases, moderation of this product may be more adaptable.

The failure rate of hypospadiac repair (using the latest procedures) for the first operation, done on children age 10 to 12 months is from 2 to 25 percent depending on the position of the hypospadias meatus. For magpi corrections the failure rate is 2 percent. If the meatus is between the scrotum and anus the failure rate is 25 percent. If buccal mucosa is used the failure rate under these same circumstances is 25 percent. However, after the second or third operation there is no difference between an operation using foreskin or foreskin mucosa and an operation using buccal mucosa. Ninety percent of second operations are to repair fistulas and have a 90 percent success rate. Ten percent of second operations are done to repair other failures such as dribbling, sprayed stream, chordee regression, ejaculation difficulties, etcetera.

 

Post Operative Complications

Our usage of the term post operative complications, refers to complications that are not a direct result of the operation but that are developed months or years later without any evidence that they began immediately after the operation and took months or years to develop. There are many penile deformities mentioned in textbooks and articles about urethroplasty, not all of them are related to urethroplasty. The more severe the hypospadias the greater is the area of operation which increases the chances of post operative complications. I will now list and explain somewhat the more common complications.

1. Fistulas has been discussed before and I should mention another major cause. The urethral skin canal is a skin tube and not a normal muscular tube lined with spongy tissue. Therefore, even if skin from the urethral plate is used, fistula may develop starting from the skin canal and extending to the outside.

2. A stricture is a narrowing of the urethral skin canal that causes difficulty in urinating and ejaculation. A major factor in this post operative complication is because the urethral skin canal is not a normal muscular tube with multiple layers and a strong tone, it is a paper thin skin tube with a weak tone.

This urethral skin canal may also expand in diameter or stretch as he grows older. This condition causes a weaker urinary flow and a weaker ejaculation sometimes necessitating milking the urethra. A blockage in the skin canal is another factor that could cause this. The force of the urine flow passing through will stretch the tube and sometimes make it baggy like a sack causing a build up of urine which results in dribbling or a sprayed stream. This also causes a build up of semen making it necessary to milk the urethra in order to release his sperm into the vagina. The physics of it is that the force is dependent on the molecular structure of the liquid, the force on the liquid, and the length and diameter of the tube. If the diameter is greater the force is weaker. Therefore, since the urinary force is stronger than the ejaculatory force, he may not realize that the skin tube was stretched until many years later when he has problems during ejaculation. With the new procedures for urethroplasty the narrowing or stretching of the skin tube is rare.

In general, the force of ejaculation is somewhat diminished after urethroplasty because the skin canal is not a muscular tube with multiple layers and a strong tone. This however does not diminish his chances of having children. The force of ejaculation is also diminished before urethroplasty because of the hypospadias meatus. When the semen hits the wall of the inner urethra it looses force and is forced out the meatus at an angle.

3. Internal scarring may develop along the urethral skin canal causing meatal discomfort or a sensation of burning during urination and pain during ejaculation that leads to a lack of sexual desire. When a highly skilled surgeon uses the latest procedures, internal scarring is rare.

4. External scarring may develop along the area of the urethroplasty causing discomfort during intercourse that leads to a lack of sexual desire. When a highly skilled surgeon uses the latest procedures, external scarring is rare.

5. Post operative chordee regression causes discomfort during intercourse with both partners leading to a lack of sexual desire. If the regression is severe, he may not be able to have intercourse. There are also cases where the chordee cannot be fully corrected.

An adult does not heal as well as an infant after urethroplasty. A circumcised male must use detached buccal mucosa which is an added factor in the percentage of failures and post operative complications. However, today a highly skilled surgeon can correct these failures and complications. An adult's decision if to operate will depend on his social and psychological situation and the medical opinion on the failure rate and the type of post operative complications to be expected and the chances of occurrence.

I will now discuss pre-operative hypospadias meatus deformities in relation to leading a normal married life which in my opinion should be considered with the pros and cons when deciding if a urethroplasty should or should not be done.

Many hypospadias infants also have a narrow urinal orifice that makes urinating difficult and must be immediately cut around to widen the orifice.

If the hypospadias meatus is along the first third of the penis where the apex is at the tip of the glans, he will be able to deposit his semen at the opening of the cervix and cause pregnancy, as will be explained. If it is located from the end of the first third of the shaft until mid-shaft, in most cases he would succeed. If it is located from mid- shaft towards the body, in most cases he will not succeed in causing pregnancy. The closer the meatus is towards the body the odds to be able to cause pregnancy diminish due to the distance from the apex. All this is if the chordee is not that severe and he is able to have intercourse. He can still produce children with artificial insemination using his sperm and his wife's egg.

There are theories that link the hormone deficiency that causes severe hypospadias with the semen deficiency often found in severe hypospadias.

In the case of a severe chordee where he cannot have intercourse, he cannot marry and cannot produce children. In this case an adult may reconsider and get second and third opinions if to have the urethroplasty done.

The force of ejaculation is not a factor in producing children. The penetration of sperm into the uterus is a chemical and muscular process that is not related to the force of ejaculation. Even if there is no significant force in his ejaculation, but as long as the sperm is milked or dribbles downward into the cervix it can penetrate into the uterus. The force of ejaculation does not move the sperm forward as a shotgun moves its mini metal pellets forward. Sperm are like mini creatures with their own instincts in a fluid of semen, the semen is shot forward while the sperm move about in the semen in different directions.

The process of entering the uterus is accomplished in two stages. The first stage is swimming through the cervix. The second stage is swimming through the uterus to meet an egg and begin fertilization.

The cervix contains a very thick fluid that protects the opening of the uterus, it is called cervical mucus. The chemical process of swimming through the cervix is also a molecular one. The semen must be deposited in close proximity to the cervix for stage one to begin. Then, phalanges of sperm begin to penetrate the cervical mucus eventually forming a single file line of one or two spermatozoa in width. Once the initial penetration is completed, more sperm can easily continue across this bridgehead into the cervix. The sperm are directed forward by the molecular structure of the cervical mucus. Some of the more energetic fast forward swimmers get ahead and enter the uterus immediately. Most sperm enter the cavities along the inside of the wall of the cervix where they are stored and are slowly released into the uterus. The sperm that can only move in a curved path or wiggle in one place do not make it through the cervix.

When in the uterus, the sperm continue their swimming to the fallopian tube aided by the contraction of the uterus.

Sperm deposited without intercourse such as is done with artificial semination are quite capable of reaching the fallopian tube and causing fertilization.

 

Halachik Discourse

Anterior Hypospadias with Mild Chordee

If the hypospadias meatus is in the first third of the penis (area of the glans), he can have normal intercourse producing children. This defect should not be a cause of embarrassment since in a public establishment he has the option of entering an enclosed toilet instead of using a urinal. Furthermore, in urethroplasty there is always a chance of post operative scaring that may bother him during intercourse, and in more severe cases cause a lack of desire to have relationship, and affect the appearance of the organ whose appearance he wished to correct through urethroplasty. Since this operation is not a medical necessity, it is not permitted to put off the circumcision for the purpose of performing a urethroplasty.

There are always people who will exaggerate a situation when seeing a hypospadias deformity and it can torment them. If an adult with a hypospadias is tormented by his situation then he may undergo the urethroplasty. If the parents of an infant are tormented by their baby's hypospadias we may very well assume that if they will not be allowed to authorize the operation according to the halacha, then they will influence their grown child to undergo a urethroplasty. Therefore, in a case like this it is advisable to have it done as an infant and avoid the post operative complications of an adult urethroplasty. In these cases it is to be done only if it recommended by several of the most successful pediatric urologists that specialize in urethroplasty, with the approval of a Rabbi well versed in medical halacha.

The area of operation with anterior hypospadias is relatively small and usually the surgeon will tell the mohel not to detach the foreskin mucosa when he performs the circumcision, and to leave some of the foreskin attached. The mohel must cut away most of the foreskin both in the latitude direction and in the longitude or circumference of the glans, exposing most of glans including the corona. Afterwards, both the remaining foreskin and the foreskin mucosa must be brought down below the corona and fashioned so that they will not by themselves return to cover the corona.

In rolling a tube they use skin from the urethral plate of the penis. This is regular body skin and not foreskin or mucosa. If more skin is needed they can always use foreskin mucosa. If this is not enough, they can use buccal mucosa.

After performing the circumcision it is forbidden to cover or attach any type of skin to the glans in a way that he will appear uncircumcised. If the graft does not reach the corona it is permitted because it does not appear as foreskin. Therefore, it is forbidden to attach any skin of any longitude thickness from the corona along most of the latitude of the glans. Likewise it is forbidden to attach any skin of any latitude length across most of the longitude or circumference of the corona.

In the case of a mild chordee, this defect can cause annoyance during intercourse and is justification to undergo an operation to correct the chordee.

 

Middle and Posterior Hypospadias and Severe Chordee

If the position of the hypospadias meatus is from below the first third of the penis (under the corona) until the middle of the shaft, it is questionable if he can have children through intercourse. If the position is from mid shaft towards the body he most likely cannot have children through intercourse. He can however have children through artificial insemination with his own sperm. This is sufficient reason to permit him to undergo urethroplasty but not to put off a circumcision since he can have children. The guidelines for performing the circumcision and the urethroplasty are the same as stated before.

The greater the area of the urethroplasty the more the complications both during the operation and after the operation. The older the patient, the complications become greater per increase in area of the urethroplasty. Adults are advised to take into consideration their personal problems before deciding if to undergo a urethroplasty. Post operative scarring can cause much discomfort during intercourse to the extent that he loses his desire for intercourse. With today's procedures these cases are rare and almost always correctable. If his defect is an obstacle with finding a wife or with his present marriage, then he should consult two or three renown experts in urethroplasty and a Rabbi who is well versed in medical halacha.

If his chordee is severe to the degree that he cannot penetrate and have intercourse causing a serious barrier to marriage, then this defect prevents him from having children. Theoretically, this would be sufficient grounds to put off the circumcision, if putting it off will enable him to have children. However, since it is not necessary to put off the circumcision to enable him to have children because they could substitute buccal mucosa for foreskin, therefore, the circumcision must be done on time or at the first chance that it can be done, even if it may be necessary to do an extra procedure by sectioning buccal mucosa.

Even if he is a circumcised adult he is required to undergo surgery to correct the chordee so that he may marry and produce children, and even if they can only use buccal mucosa which lower the success rate of the first operation and an be the cause for a greater rate of post operative complication.

If a mohel is asked to come to a urethroplasty to perform a circumcision according to the surgeons instructions, he must first consult with the surgeon. If the surgeon will forbid him to perform a halachik circumcision as explained before, then he may not participate in a Bris, and the surgeon during surgery will do away with the foreskin without the Bris ceremony, as explained before.

 

Post Operative Complications

Post operative fistula are orifices leading from the urethral skin canal to the outside, and are in the category of defects called "kerus shofchoh" disqualifying him from marriage. If it is repaired he is no longer disqualified. Fistula should be repaired immediately because they interfere with intercourse and maturation of the sperm.

If the infant was born with an abnormally narrow urinal orifice, the surgeon may cut skin around the orifice to widen it to normal size.

If his sperm does not shoot forward but remains in the urethra and he must milk his urethra to eject his sperm to near the uterus opening, we must check the cause. If it is because the artificial urethra skin tube widened but the natural urethra did not then this is not a disqualifying deformity. If a stricture occurs, that is, the skin tube urethra narrowed causing difficulty in ejaculation, he is a "kerus shofchoh" until it is repaired.

Post operative scarring that causes pain during intercourse resulting in losing his desire for intercourse and a psychological inability to produce an erection, is not a disqualifying defect.

A severe chordee that does not allow him to have intercourse is not a disqualifying defect even if it was caused by an accident. However, there may be a disqualifying defect accompanied by the chordee.

The father of a hypospadias child must first consult with a Rav who is a posek. Afterwards, the parent and the mohel should consult with the surgeon. It is expected that the surgeon will offer his professional opinion about the proper way to perform the operation. Buccal mucosa will not be mentioned as an option because this requires an extra procedure and it is detached from its blood supply. If the surgeon requires an amount of foreskin that if left the Bris cannot be performed according to halacha, the mohel should explain that according to halacha he can leave the foreskin mucosa and foreskin that most has been cut away both in the latitude direction and in the longitude or circumference of the glans, exposing most of glans including the corona. Afterwards, both the remaining foreskin and the foreskin mucosa must be brought down below the corona and fashioned so that they will not by themselves return to cover the corona. If the surgeon needs more skin he may use buccal mucosa, and he may use the foreskin mucosa and the foreskin that has been left to cover the wounds according to halacha.

If the infant was born with an immature penis and on the eighth day the corona was covered with foreskin along most of its longitude or circumference, although not along most of its latitude, the circumcision must be performed and not put off until it is fully grown in order to avoid a second circumcision when it is fully grown. If after the circumcision the foreskin grows and covers most of the circumference of the corona, then he is required to perform a second circumcision.

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