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ULAANBAATAR PROCEDURE FOR TUBULARIZATION OF THE GLANSIN SEVERE HYPOSPADIAS

P. A. DEWAN,* G. ERDENETSETSEG AND D. CHIANG From the Urology Unit, Sunshine Hospital, Kids Urology Research Group (PAD, DC) and Department of Paediatrics, University of Melbourne

(PAD, DC), Victoria, Australia, and Urology Department, Maternal and Child Medical Research Centre, Ulaanbaatar, Mongolia (GE)

ABSTRACT

Purpose: We developed a new procedure for the repair of proximal hypospadias in which thedistal urethra is constructed as part of the first of 2 stages, and reviewed the results of 34 cases.

Materials and Methods: We performed stage 1 of the Ulaanbaatar procedure in 35 children 0.6to 11 years old (average age 2.5), and stage 2 in 20. The meatus was at the posterior third of theshaft in 14 children, at the penoscrotal junction in 16 and in the perineum in 5. Three patientshad a previous operation, and none had Byars flaps formed. Followup was less than 2 1 ⁄ 2 years forstage 1 and less than 1 1 ⁄ 2 years for stage 2. In 2 stage 2 procedures a free graft was also used toaugment the proximal part of the urethroplasty.

Results: Urethral fistula did not develop in any patient, a minor early stricture occurred in 2patients and 1 urethral diverticulum occurred in 1 patient after stage 2. In all patients the glansand meatus were more normal compared to other 2-stage procedures after the first operation, andthe cosmetic result was usually satisfactory.

Conclusions: The Ulaanbaatar technique provides an alternative approach to the formation of the glans urethra in severe hypospadias. It does not have the risks associated with a single stageprocedure but has the benefit of enabling tunneling of the urethra through the glans, thusfacilitating a favorable cosmetic outcome and an easy stage 2.

K EY WORDS : hypospadias, urethra, penis

Posterior hypospadias represents approximately 30% of allcases of hypospadias. 1 The goals of surgical management of severe hypospadias include chordee release and, thus, theconstruction of a straight penis, bridging the deficiency in theurethral plate positioning of the meatus on the penile tip,

normalization of voiding and erections, and the creation of aurethra of uniform caliber while aiming to produce a sym-metric appearance of glans and shaft. 2

From Heliodor Antyl’s earliest recorded description of hy-pospadias in the first century A.D. 3 several hundred differentsurgical corrections have been suggested. Retik et al notedthat they have seen the pendulum of hypospadias surgeryswing widely in the last 3 decades. 4 In the 1950s the acceptedmethod of surgical management of hypospadias involved a2-stage approach. 4 Devine and Horton performed 1-stagerepairs in the 1960s using a free graft of preputial skin. 5

Since then numerous ingenious methods have been intro-duced to repair hypospadias with a single stage approach.For example Standoli 6 and Duckett 7 incorporated the prepu-tial skin in a vascularized fashion for hypospadias correction

and further expanded the use of 1-stage repairs. By 1988 itwas suggested that all primary hypospadias repairs shouldinvolve a single stage approach, 8 but the results did not liveup to expectations with complication rates usually reportedto be between 7.5% and 17%. 2, 8 However, several authorsreported rates of 25% to 52%. 9,10

Single and multiple stage repairs have their proponentsand, certainly, a unified approach to all patients is not pos-sible since surgery should be individualized according to theparticular anomaly being treated. 11 Nevertheless because of the problems of single stage repairs we believe a 2-stageapproach best serves most patients with posterior hypospa-

dias. In this report we introduce a new 2-stage procedure forthe repair of proximal hypospadias which was first per-formed in Ulaanbaatar, the capital city of Mongolia. In thisprocedure the distal urethra is constructed as part of the firstof 2 stages, with the advantage of tunneling the urethra

through the glans as in some single stage operations, butwith the added safety of a 2-stage approach.

MATERIALS AND METHODS

A total of 35 boys were selected to undergo 2-stage hypos-padias repair using the Ulaanbaatar technique. The boysranged in age from 0.6 to 11 years with a mean age of 2.5years. Of the 35 patients 20 underwent both stages of surgeryin 4 countries. The meatus was at the posterior third of theshaft in 14 patients at the penoscrotal junction in 16 and inthe perineum in 5. Three patients had previous operationswith inadequate chordee release but none of them had Byarsflaps formed previously.

Surgical technique—stage 1. A stabilizing suture of 5-zeropolypropylene was placed in the dorsum of the glans followedby a subcoronal circumferential incision across the urethralplate (fig. 1, A), allowing degloving and chordee release (fig.1, B). Byars flaps were then created (fig. 1, C), and the innerand outer layers of the foreskin separated (fig. 1, D). Theflaps were rotated to the ventral aspect of the penis andsutured together in the midline with 7-zero polyglactin (fig.1, E ). Two longitudinal paramedian incisions were made toallow the distal portion of the prepuce to be tubularized (fig.1, F ), resulting in a distal urethra with a ventral and dorsalsuture line. The distal neourethra (fig. 1, G) was then tun-neled through the glans (fig. 1, H ). The operation was con-cluded by suturing the distal urethra to the glans and com-pleting the skin closure (fig. 1, I ). A silicone catheter wasinserted into the bladder in all but the last 4 patients who

were not intubuted, and a urethral stent was left in the distalreconstructed urethra in all patients.

Accepted for publication October 24, 2003.* Correspondence and requests for reprints: P.O. Box 152,

Parkville 3052, Victoria, Australia (telephone: 61-3-8345 001; FAX:61-3-8345 1278; e-mail: Paddy.Dewan@wh.org.au).

0022-5347/04/1713-1263/0 Vol. 171, 1263–1265, March 2004THE J OURNAL OF U ROLOGY ® Printed in U.S.A.Copyright © 2004 by A MERICAN U ROLOGICAL ASSOCIATION DOI: 10.1097/01.ju.0000113425.79116.b6

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Stage 2. From 6 to 10 months after stage 1 the previouslytransferred preputial skin was used to form the mid penileurethra. A U-shaped incision was made (fig. 2, A) on theproximal urethral meatus and joined to an invertedU-shaped incision on the proximal end of the glans urethra.

A tension-free urethral closure was performed with continu-ous subcuticular 7-zero polyglactin suture (fig. 2, B) and alayered closure of the wound completed (fig. 2, C) with 7-zeropolyglactin. A dripping urethral stent was usually left todrain the bladder into the diaper in patients younger than 2years and a feeding tube was inserted to drain the bladder inolder boys.

The urinary diversion for stage 1 was removed after 1 dayand for stage 2 removed after 7 to 10 days. The distal ure-thral catheter of stage 1 was removed between days 5 and 7. An adhesive dressing was applied to the penile shaft andglans after each stage and was removed on the same day as

the urethral catheter. In 2 stage 2 procedures a penile skinfree graft was used to augment the diameter of the proximalurethra and thus avoid the use of hair bearing skin.

RESULTS

Followup was less than 2.5 years in patients who under-went stage 1 only and less than 1.5 years for patients whounderwent stage 2. Pouting skin developed in 1 patient, anda urethral diverticulum developed in 1 and was subsequently

repaired without further complications. After stage 2 therewere 2 patients in whom early stricture developed at proxi-mal anastomosis, and they were treated with urethral dila-tion over a lubricated glide wire. In all patients the glans andmeatus were more normal after 1 (fig. 3) than in other2-stage procedures, and the cosmetic results from stage 2were satisfactory judging by the postoperative appearance of glans, meatus and penile shaft (fig. 4). Stenosis of the glansurethra did not develop in any of the patients.

DISCUSSION

Proximal hypospadias represents approximately 20% to30% of all such penile defects. Techniques for the ameliora-tion of posterior hypospadias include 1-stage repair with

adjacent skin flaps, vascularized flaps, free skin, bladder orbuccal mucosa grafts or a 2-stage procedure. The most pop-ular 2-stage operations were those of Thiersch and Duplay,which has been well described and modified by Byars. 12 Al-though the Thiersch-Duplay technique has been furthermodified by numerous surgeons the surgical concept hasremained unchanged. 4

Most cases of proximal hypospadias can be treated with a1-stage repair, but with a high complication rate includingmeatal stenosis, urethral stricture, urethrocutaneous fistulaand urethral diverticulum. 4,5 ,8 – 10 As background to singlestage techniques, use of bladder mucosa as a 1-stage hypos-padias repair was first described in 1947, and was revived byColeman et al. 14 However, a review of 268 reported cases in1990 by Keating et al was not as encouraging as initiallybelieved. 15 The main complications were meatal problems inthat 30% of patients had eversion of the bladder mucosa, aproblem also noted by Kinkead et al. 16 The buccal mucosagraft was subsequently suggested, with tissue harvestedfrom the inner cheek or the inner surface of the lip. 17 How-ever, buccal mucosa-free grafts have a high urethral stricturerate. 18

F IG . 1. Ulaanbaatar procedure for severe hypospadias. A, sub-coronal circumferential incision across urethral plate. B, penile shaftis degloved and chordee is released. C, Byars flaps are created. D,inner and outer layers of prepuce are separated. E , distal portion of foreskin is rotated ventrally and sutured in midline with continuous7-zero polyglycolic acid suture. F , two longitudinal paramedian inci-sions made to allow distal portion of prepuce to be tubularized. G,new distal urethra created and tubularized with 7-zero polyglycolicacid interrupted sutures. H , creation of tunnel through glans withsharp dissection. I , distal urethral tube brought through glans tun-nel and anastomosed to tip of glans.

F IG . 2. Stage 2 of Ulaanbaatar procedure for severe hypospadias. A, perimeatal U-shaped incision around proximal and distal meatus. B, tubularization of Duplay-type tube to form neourethra. C, secondlayer of soft tissue and skin closure completed.

F IG . 3. A, appearance before and after surgery for stage 1 of Ulaanbaatar procedure. B, patient 6 months after stage 1 of Ulaan-baatar procedure.

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Greenfield et al noted that the 2-stage repair is a safe,reliable alternative for boys with severe hypospadias, withadvantages such as the thorough correction of chordee, rec-reation of a conical glans with a normal ventral mucosalcollar, a good slit-shaped terminal meatus, a nonrotated pe-

nis with a cylindrical shape, minimal fistula formation andavoidance of severe graft stricture. 19 In contrast, Retik et alare strong proponents of the 1-stage hypospadias repair, 4

although they do believe that there is a subset of patientswith severe proximal hypospadias, chordee and small phalluswho may be best served by a 2-stage procedure. They suggestthat in such children 2-stage repair allows for a better cos-metic appearance and a lower complication rate than 1-stagerepair with a free, vascularized or composite graft.

CONCLUSIONS

In general, reconstruction using a 2-stage repair involvescorrection of chordee with the dorsal prepuce mobilized asByars flaps to resurface the ventral aspect of the penis during

stage 1. Stage 2 involves the creation of the neourethra andlayered closure. The Ulaanbaatar technique provides an al-ternative approach in which the glans urethra is created aspart of stage 1 without the risks associated with a singlestage procedure. In addition, the procedure has the benefit of enabling tunneling of the urethra through the glans, thusfacilitating a favorable cosmetic outcome for the usually con-ical glans. The relatively limited use of the Ulaanbaatartechnique thus far has not been associated with meatal ste-nosis nor stricture of the glans urethra, and it is relativelysimple compared to single stage procedures for severe hypo-

spadias. We recognize the risk of stricture of the glans ure-thra, but as yet we have not encountered this problem and, ingeneral, would recommend the Ulaanbaatar operation forproximal hypospadias.

REFERENCES

1. Duckett, J. W. and Baskin, L. S.: Hypospadias. In: PediatricSurgery, 5th ed. chapt. 116, p. 1761, 1988

2. Retik, A. B., Keating, M. and Mandell, J.: Complications of hypospadias repair. Urol Clin North Am, 15: 223, 1988

3. Hauben, D. J.: The history of hypospadias. Acta Chir Plast, 26:196, 1984

4. Retik, A. B., Bauer, S. B., Mandell, J., Peter, C. A., Colodny, A.and Atala, A.: Management of severe hypospadias with a2-stage repair. J Urol, 152: 749, 1994

5. Devine, C. J., Jr. and Horton, C. E.: A one stage hypospadiasrepair. J Urol, 85: 166, 1961

6. Standoli, L.: Correzione dell ’ipospadias in tempo unico: Techni-cal della urethroplastica con limbo ad isola prepuziale. ItalChir Ped, 21: 82, 1979

7. Duckett, J. W., Jr.: Transverse preputial island flap techniquefor repair of hypospadias. Urol Clin North Am, 7: 423, 1980

8. Sadove, R. C., Horton, C. E. and McRoberts, J. W.: The new eraof hypospadias surgery. Clin Plast Surg, 15: 341, 1988

9. DiSandro, M. and Palmer, J. M.: Stricture incidence related tosuture material in hypospadias surgery. J Pediatr Surg, 31:881, 1996

10. Hollowell, J. G., Keating, M. A., Snyder, H. M., III and Duckett,J. W.: Preservation of the urethral plate in hypospadias repair:extended applications and further experience with the onlayisland flap urethroplasty. J Urol, 143: 98, 1990

11. Bracka, A.: Hypospadias repair: the two-stage alternative. Br JUrol, suppl., 76: 31, 1995

12. Byars, L. T.: Technique for consistently satisfactory repair of hypospadias. Surg Gynecol Obstet, 100: 184, 1955

13. Flack, C. E. and Walker, R. D., III: Onlay-tube-onlay urethro-plasty technique in primary perineal hypospadias surgery.J Urol, 154: 837, 1995

14. Coleman, J. W., McGovern, J. H. and Marshall, V. F.: The blad-der mucosal graft technique for hypospadias repair. Urol ClinNorth Am, 8: 457, 1981

15. Keating, M. A., Cartwright, P. C. and Duckett, J. W.: Bladder

mucosa in urethral reconstructions. J Urol, 144: 827, 199016. Kinkead, T. M., Borzi, P. A., Duffy, P. G. and Ransley, P. G.:Long-term followup of bladder mucosa graft for male urethralreconstruction. J Urol, 151: 1056, 1994

17. Hodgson, N. B.: A one-stage hypospadias repair. J Urol, 104:281, 1970

18. El-Kasaby, A. W., Fath-Alla, M., Noweir, A. M., El-Halaby,M. R., Zakaria, W. and El-Beialey, M. H.: The use of buccalmucosa patch graft in the management of anterior urethralstrictures. J Urol, 149: 276, 1993

19. Greenfield, S. P., Sadler, B. T. and Wan, J.: Two-stage repair forsevere hypospadias. J Urol, 152: 498, 1994

F IG . 4. Postoperative results after stage 2 of Ulaanbaatar proce-dure in 2 separate patients.

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