Chatterjee Uday Sankar, Basak Dhananjay
Visiting Paediatric Surgeon, Park Medical Research and Welfare Society, Kolkata, West Bengal, India.
J Indian Assoc Pediatr Surg. 2022 Nov-Dec;27(6):684-688. doi: 10.4103/jiaps.jiaps_26_22. Epub 2022 Nov 14.
Two stage urethroplasty for proximal penile hypospadias is time consuming, expensive and; traumatic both for parents and phallus. On the other hand, single stage procedure technically demanding. We would like to describe Extended Ulaanbaatar Procedure (EUP) which is not a two stage procedure. Rather, might be called as 'extended single stage' procedure. In EUP we have done orthoplasty along with urethroplasty with preputial skin graft at same sitting as primary procedure keeping urination diverted through proximal hypospadiac meatus as "controlled fistula" which was closed after six months as secondary procedure.
We operated on 35 patients of proximal penile hypospadias with moderate to severe chordee. Chordee was excised till correction of curvature. Two distracted cut ends of native plate was bridged with preputial skin graft (PSG) in between. Following that, silastic tube was placed over glandular plate as scaffold, on both cut ends of native plate and PSG. All the urethral plates and PSG were buried with tunica vaginalis flap before glanuloplasty. After six months, proximal "controlled fistula" was closed with scrotal dartos fascia and skin to join distal to proximal urethra.
Vertical meatus in glans was found in 32 patients. One patient had glans dehiscence, two patients had medium sized fistula, another two patients had stenosis in neourethra and six had suture track fistula. Twenty-nine patients had satisfactory curve with good flow in uroflowmetry as per nomogram at sixth month of follow up.
In classic Ulaanbaatar procedure authors do distal urethroplasty and glanuloplsaty in 1 stage following orthoplasty to avoid repeat trauma in glans in repeat procedures. Left over urethroplasty in classic Ulaanbaatar was done in 2 stage. However, in EUP; we did urethroplasty for full length following orthoplasty as primary procedure. This procedure is less invasive than two staged as we avoided repeat degloving and repeat dissection on operated tissues. Urethroplasty done as primary procedure shunned the need of repeat degloving, decreased the period of morbidity, stay, and cost of surgery. We also avoided problems of urination through not matured, long, neo-urethra. Similarly complications i.e disruption, stenosis in neo-urethra can be managed utilizing the advantages of urinary diversion.
近端阴茎型尿道下裂的两期尿道成形术耗时、昂贵，且对患儿父母和阴茎均造成创伤。另一方面，一期手术技术要求高。我们想要描述一种并非两期手术的扩展乌兰巴托手术（EUP）。确切地说，它可被称作“扩展一期”手术。在EUP中，我们在一期手术时同时进行阴茎下弯矫正术和尿道成形术，并采用包皮皮瓣移植，通过近端尿道下裂尿道口进行尿液改道作为“可控瘘”，六个月后作为二期手术关闭该瘘口。
我们对35例患有中度至重度阴茎下弯的近端阴茎型尿道下裂患者进行了手术。切除阴茎下弯直至矫正弯曲。在天然尿道板的两个分离断端之间用包皮皮瓣（PSG）进行桥接。随后，将硅橡胶管置于阴茎头尿道板上作为支架，放置在天然尿道板和PSG的两个断端上。在阴茎头成形术前，所有尿道板和PSG均用睾丸鞘膜瓣覆盖。六个月后，用阴囊肉膜筋膜和皮肤关闭近端“可控瘘”，以连接尿道远端和近端。
32例患者阴茎头出现垂直尿道口。1例患者阴茎头裂开，2例患者出现中等大小的瘘管，另外2例患者新尿道狭窄，6例患者出现缝线道瘘。根据随访第六个月的列线图，29例患者阴茎弯曲矫正满意，尿流率良好。
在经典的乌兰巴托手术中，作者在阴茎下弯矫正术后一期进行远端尿道成形术和阴茎头成形术，以避免再次手术对阴茎头造成重复创伤。经典乌兰巴托手术中剩余的尿道成形术分两期进行。然而，在EUP中，我们在阴茎下弯矫正术后一期进行全程尿道成形术。该手术比两期手术侵入性小，因为我们避免了对手术组织进行重复的脱套和重复解剖。一期进行尿道成形术避免了重复脱套的需要，缩短了发病时间、住院时间和手术费用。我们还避免了通过未成熟、过长的新尿道排尿的问题。同样，利用尿液改道的优势可以处理新尿道破裂、狭窄等并发症。
