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The Modified “Ulaanbaatar” Procedure for Proximal Hypospadias Repair
Megan S. Schober, MD, PhD, Seth A. Alpert, MD, Venkata R. Jayanthi, MD.
Nationwide Children's Hospital, Columbus, OH, USA.

Background: The “Ulaanbaatar” procedure for proximal hypospadias was described by Dewan as a modification of the classic 2-stage procedure in which the glanular urethra is constructed during the first stage. During the second stage, the penile skin between the true proximal meatus and the distal urethra is tubularized, as in a Johanson urethroplasty. Since the glans is only touched once, there is the potential for a better cosmetic outcome.
Methods: We retrospectively reviewed all patients who completed the second stage of the repair. We evaluated demographics, original meatal location, technique of chordee correction, technique of glanular urethra reconstruction and overall outcomes and complications. The first stage is analogous to a classic repair with regard to urethral plate division and chordee correction (plication vs ventral grafting). However, rather than swinging in flaps into a split glans for later tubularization, an island flap is mobilized from preputial skin, tubularized, and brought through the glans. The remaining penile skin is used for skin coverage and to bridge the true meatus and the distal neourethra. Six months later, the midline skin is tubularized reconstructing the urethra from the proximal meatus to the glanular neourethra constructed at the first stage.
Results: The series consists of all 20 boys who have completed both stages of the repair. Mean age at surgery was 20.8 months (median 10.1, range 6 - 118). Initial urethral meatal location was scrotal in 14/20 (70%) and perineal in 6/20 (30%). Seventeen (85%) received pre-operative testosterone or HCG. After urethral plate transection, persistent curvature was addressed during the first stage of the procedure with dorsal plication (11/20; 55%), urethral plate transection alone (6/20; 30%) or ventral grafting with small intestinal submucosa (SIS) (3/20; 15%). Sixty percent (12/20) had the neourethra tunneled through the glans and 40% (8/20) had the glans split followed by glanuloplasty. Average time between the two stages was 6.6 months (range 4.0 - 10.6 months). Bifid scrotum/penoscrotal transposition was corrected at the first stage in 2 and at the second in 14.
Two patients developed complications (10%). One developed recurrent epididymitis related to an abnormal ejaculatory duct (no stricture) and underwent vasectomy. Another did develop a urethral diverticulum and subsequent scrotal abscess. Mean length of follow up is 10 months (0.3 to 49).
Conclusions: Our modification of the Ulaanbaatar procedure involves the formation of a true, tubularized island flap of preputial skin to create the distal urethra during the first stage. The distal urethra remains patent in between the two stages even though nothing is passing through it. The modified Ulaanbaatar technique maximizes the potential cosmetic appearance as the glans is only touched once and also does permit a “tunneled” distal urethra. Its use is applicable to the most severe cases and allows for simultaneous correction of penoscrotal transposition and bifid scrotums.

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