0022-5347/04/1713-1263/0 Vol.

171, 1263–1265, March 2004

THE JOURNAL OF UROLOGY® Printed in U.S.A.
Copyright © 2004 by AMERICAN UROLOGICAL ASSOCIATION DOI: 10.1097/01.ju.0000113425.79116.b6

ULAANBAATAR PROCEDURE FOR TUBULARIZATION OF THE GLANS

IN 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 the
distal 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 0.6
to 11 years old (average age 2.5), and stage 2 in 20. The meatus was at the posterior third of the
shaft in 14 children, at the penoscrotal junction in 16 and in the perineum in 5. Three patients
had a previous operation, and none had Byars flaps formed. Followup was less than 21⁄2 years for
stage 1 and less than 11⁄2 years for stage 2. In 2 stage 2 procedures a free graft was also used to
augment the proximal part of the urethroplasty.
Results: Urethral fistula did not develop in any patient, a minor early stricture occurred in 2
patients and 1 urethral diverticulum occurred in 1 patient after stage 2. In all patients the glans
and meatus were more normal compared to other 2-stage procedures after the first operation, and
the 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 stage
procedure but has the benefit of enabling tunneling of the urethra through the glans, thus
facilitating a favorable cosmetic outcome and an easy stage 2.
KEY WORDS: hypospadias, urethra, penis

Posterior hypospadias represents approximately 30% of all
cases of hypospadias.1 The goals of surgical management of
severe hypospadias include chordee release and, thus, the
construction of a straight penis, bridging the deficiency in the
urethral plate positioning of the meatus on the penile tip,
normalization of voiding and erections, and the creation of a
urethra 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 different
surgical corrections have been suggested. Retik et al noted
that they have seen the pendulum of hypospadias surgery
swing widely in the last 3 decades.4 In the 1950s the accepted
method of surgical management of hypospadias involved a
2-stage approach.4 Devine and Horton performed 1-stage
repairs 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 Standoli6 and Duckett7 incorporated the prepu-
tial skin in a vascularized fashion for hypospadias correction
and further expanded the use of 1-stage repairs. By 1988 it
was suggested that all primary hypospadias repairs should
involve a single stage approach,8 but the results did not live
up to expectations with complication rates usually reported
to be between 7.5% and 17%.2, 8 However, several authors
reported rates of 25% to 52%.9, 10
Single and multiple stage repairs have their proponents
and, certainly, a unified approach to all patients is not pos-
sible since surgery should be individualized according to the
particular anomaly being treated.11 Nevertheless because of
the problems of single stage repairs we believe a 2-stage
approach best serves most patients with posterior hypospa-
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).
1263
dias. In this report we introduce a new 2-stage procedure for
the repair of proximal hypospadias which was first per-
formed in Ulaanbaatar, the capital city of Mongolia. In this
procedure the distal urethra is constructed as part of the first
of 2 stages, with the advantage of tunneling the urethra
through the glans as in some single stage operations, but
with 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 boys
ranged in age from 0.6 to 11 years with a mean age of 2.5
years. Of the 35 patients 20 underwent both stages of surgery
in 4 countries. The meatus was at the posterior third of the
shaft in 14 patients at the penoscrotal junction in 16 and in
the perineum in 5. Three patients had previous operations
with inadequate chordee release but none of them had Byars
flaps formed previously.
Surgical technique—stage 1. A stabilizing suture of 5-zero
polypropylene was placed in the dorsum of the glans followed
by a subcoronal circumferential incision across the urethral
plate (fig. 1, A), allowing degloving and chordee release (fig.
1, B). Byars flaps were then created (fig. 1, C), and the inner
and outer layers of the foreskin separated (fig. 1, D). The
flaps were rotated to the ventral aspect of the penis and
sutured together in the midline with 7-zero polyglactin (fig.
1, E). Two longitudinal paramedian incisions were made to
allow the distal portion of the prepuce to be tubularized (fig.
1, F), resulting in a distal urethra with a ventral and dorsal
suture 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 was
inserted into the bladder in all but the last 4 patients who
were not intubuted, and a urethral stent was left in the distal
reconstructed urethra in all patients.
1264 ULAANBAATAR PROCEDURE FOR TUBULARIZATION OF GLANS IN HYPOSPADIAS
FIG. 1. Ulaanbaatar procedure for severe hypospadias. A, sub-
coronal circumferential incision across urethral plate. B, penile shaft
is 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 continuous
7-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 polyglycolic
acid interrupted sutures. H, creation of tunnel through glans with
sharp dissection. I, distal urethral tube brought through glans tun-
nel and anastomosed to tip of glans.
Stage 2. From 6 to 10 months after stage 1 the previously
transferred preputial skin was used to form the mid penile
urethra. A U-shaped incision was made (fig. 2, A) on the
proximal urethral meatus and joined to an inverted
U-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 a
layered closure of the wound completed (fig. 2, C) with 7-zero
polyglactin. A dripping urethral stent was usually left to
drain the bladder into the diaper in patients younger than 2
years and a feeding tube was inserted to drain the bladder in
older boys.
The urinary diversion for stage 1 was removed after 1 day
and 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 and
glans after each stage and was removed on the same day as
FIG. 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, second
layer of soft tissue and skin closure completed.
the urethral catheter. In 2 stage 2 procedures a penile skin
free graft was used to augment the diameter of the proximal
urethra 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 who
underwent stage 2. Pouting skin developed in 1 patient, and
a urethral diverticulum developed in 1 and was subsequently
repaired without further complications. After stage 2 there
were 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 and
meatus were more normal after 1 (fig. 3) than in other
2-stage procedures, and the cosmetic results from stage 2
were satisfactory judging by the postoperative appearance of
glans, meatus and penile shaft (fig. 4). Stenosis of the glans
urethra did not develop in any of the patients.
DISCUSSION
Proximal hypospadias represents approximately 20% to
30% 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 or
buccal 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 further
modified by numerous surgeons the surgical concept has
remained unchanged.4
Most cases of proximal hypospadias can be treated with a
1-stage repair, but with a high complication rate including
meatal stenosis, urethral stricture, urethrocutaneous fistula
and urethral diverticulum.4, 5, 8 –10 As background to single
stage techniques, use of bladder mucosa as a 1-stage hypos-
padias repair was first described in 1947, and was revived by
Coleman et al.14 However, a review of 268 reported cases in
1990 by Keating et al was not as encouraging as initially
believed.15 The main complications were meatal problems in
that 30% of patients had eversion of the bladder mucosa, a
problem also noted by Kinkead et al.16 The buccal mucosa
graft was subsequently suggested, with tissue harvested
from the inner cheek or the inner surface of the lip.17 How-
ever, buccal mucosa-free grafts have a high urethral stricture
rate.18
FIG. 3. A, appearance before and after surgery for stage 1 of
Ulaanbaatar procedure. B, patient 6 months after stage 1 of Ulaan-
baatar procedure.
 ULAANBAATAR PROCEDURE FOR TUBULARIZATION OF GLANS IN HYPOSPADIAS
FIG. 4. Postoperative results after stage 2 of Ulaanbaatar proce-
dure in 2 separate patients.
Greenfield et al noted that the 2-stage repair is a safe,
reliable alternative for boys with severe hypospadias, with
advantages such as the thorough correction of chordee, rec-
reation of a conical glans with a normal ventral mucosal
collar, a good slit-shaped terminal meatus, a nonrotated pe-
nis with a cylindrical shape, minimal fistula formation and
avoidance of severe graft stricture.19 In contrast, Retik et al
are strong proponents of the 1-stage hypospadias repair,4
although they do believe that there is a subset of patients
with severe proximal hypospadias, chordee and small phallus
who may be best served by a 2-stage procedure. They suggest
that in such children 2-stage repair allows for a better cos-
metic appearance and a lower complication rate than 1-stage
repair with a free, vascularized or composite graft.
CONCLUSIONS
In general, reconstruction using a 2-stage repair involves
correction of chordee with the dorsal prepuce mobilized as
Byars flaps to resurface the ventral aspect of the penis during
stage 1. Stage 2 involves the creation of the neourethra and
layered closure. The Ulaanbaatar technique provides an al-
ternative approach in which the glans urethra is created as
part of stage 1 without the risks associated with a single
stage procedure. In addition, the procedure has the benefit of
enabling tunneling of the urethra through the glans, thus
facilitating a favorable cosmetic outcome for the usually con-
ical glans. The relatively limited use of the Ulaanbaatar
technique thus far has not been associated with meatal ste-
nosis nor stricture of the glans urethra, and it is relatively
simple compared to single stage procedures for severe hypo-
1265
spadias. We recognize the risk of stricture of the glans ure-
thra, but as yet we have not encountered this problem and, in
general, would recommend the Ulaanbaatar operation for
proximal hypospadias.
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