Columbus, OH — July 2017
Because of the complexity of proximal hypospadias, no one procedure has proven to be the best option for correcting the condition. Many pediatric urologists use a two-stage strategy: in the first stage, penile curvature is corrected, the glans is split and tissue is laid onto the split glans; in the second, the transposed tissue is made into a tube and the urethra is reconstructed to the glans.
While often successful, that strategy means the glans must be operated on twice. A complication rate as high as 50 percent has been reported.
A different two stage strategy, first described in 2004 as the “Ulaanbaatar procedure” and modified in recent years at Nationwide Children’s Hospital, allows for just a single glans procedure. A study from urologists at Nationwide Children’s, published in the Journal of Pediatric Urology, reports good outcomes, fewer complications and potentially better cosmetic results with the modified Ulaanbaatar procedure.
“These cases of proximal hypospadias are some of the most challenging conditions we see in pediatric urology,” says V. Rama Jayanthi, MD, chief of Urology at Nationwide Children’s and lead author of the study. “What we describe in our report are technically demanding procedures – more demanding than the classic two-stage approach. Pediatric urologists who are used to complex hypospadias correction can perform these procedures, though, and I think it’s worth it because of the outcomes we have seen.”
The Ulaanbaatar procedure as initially described corrects chordee in the first stage (much like a classic first stage), but also uses penile tissue to create a glanular urethra. That allows the second stage to involve tubularization of the penile skin between the native meatus and the neourethra – and avoids a second glans procedure.
The Nationwide Children’s modification of the Ulaanbaatar uses formal preputial tubularized island flaps instead of local penile skin to create the glanural urethra in the first phase, but the modification continues to avoid the second glans procedure.
The study reviewed the records of all 34 boys who underwent the two-stage modified Ulaanbaatar at Nationwide Children’s between 2009 and 2016. Hypospadias was so severe that 19 had evaluation for genital ambiguity at birth. Almost all of the patients (30) received preoperative hormonal treatment in an effort to increase glans width and penile size.
Mean age at first surgery was approximately 18 months, and mean time between first and second surgeries was seven months.
Four patients (12 percent) developed urethral diverticula requiring repair. Of particular note, no patients developed a fistula. The authors hypothesize that this low rate of fistula development is the result of the first stage’s proximal diversion of urine; conceptually, the first stage creates a “controlled fistula” that is then repaired in the second stage.
Beyond the low complication rate, cosmetic outcomes subjectively may be better, says Dr. Jayanthi, who is also a clinical professor of Surgery at The Ohio State University College of Medicine. The glans is often normally shaped in these children pre-surgery, and the classic two-stage process may change that.
“With our modified procedure, more than 60 percent of these children needed no glanular reconstruction,” he says. “We’re all aware how important appearance can be for these kids in the future, and this is a way to have the best cosmetic outcome possible with a severe abnormality.”
Jayanthi VR, Ching CB, DaJusta DG, McLeod DJ, Alpert SA. The modified Ulaanbaatar procedure: Reduced complications and enhanced cosmetic outcome for the most severe cases of hypospadias. Journal of Pediatric Urology. 2017 May 18. [Epub ahead of print]