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PubMed This is a summary of 17 peer-reviewed journal articles Updated
Pediatric Urology

Building a Path Forward: Surgical Treatment Strategies

At a Glance

The standard treatment for isolated epispadias is complex surgical reconstruction, typically performed between 6 months and 2 years of age. Primary goals include rebuilding the urethra, correcting curvature in boys, and achieving natural urinary function and appearance.

The standard treatment for isolated epispadias is surgical reconstruction. While this is a complex undertaking, the goal is straightforward: to create a body that functions naturally and looks normal. Because this condition is so rare, it is essential that the surgery is performed by a pediatric urologist who specializes in the Bladder Exstrophy-Epispadias Complex (BEEC).

The Goals of Surgery

Surgical repair focuses on three main objectives [1][2]:

  1. Urethral Reconstruction: Moving the urethral opening from the top of the genitals to the tip so that urine flows in a controlled, predictable stream [2].
  2. Chordee Correction: Straightening the upward curve of the penis (called chordee) to allow for normal function and appearance [1].
  3. Cosmetic Normalization: Reconstructing the glans (the head) and the surrounding skin to achieve a natural look [2].

Surgical Techniques for Boys

There are two primary ways surgeons approach this repair. The choice often depends on the severity of the epispadias and the surgeon’s specific expertise.

  • Modified Cantwell-Ransley (MCR): This is currently a very common and reliable approach [3]. The surgeon carefully detaches the urethral plate (the tissue that should have formed the tube) and moves it to the “bottom” side of the penis, underneath the corpora cavernosa (the two chambers that fill with blood during an erection) [2][3]. This repositioning helps straighten the penis and places the urethra in its natural anatomical position [2].
  • Complete Penile Disassembly (CPD/Mitchell Technique): In this more “radical” approach, the surgeon completely separates the penis into three separate parts: the two chambers of the corpora cavernosa and the urethral plate [4][5]. This allows for a deep, complete reconstruction. While it can provide excellent initial results, some research has shown a risk of the upward curve returning over time or potential injury to the delicate penile tissues [4][5].

Preventing Leaks with “Flaps”

The most common complication after these surgeries is a fistula, which is a small, unintended hole where urine leaks out [6]. To prevent this, surgeons often use a tunica vaginalis flap [7]. This involves taking a thin layer of healthy, blood-rich tissue from the lining around the testicles and wrapping it around the new urethral tube to act as a protective “waterproof” seal [6][8].

Surgical Strategies for Girls

For girls, the surgery is typically a single-stage procedure that addresses the cleft urethra, the bifid (split) clitoris, and the labia [9][10].

  • Sub-symphyseal Repair: This approach involves lengthening the urethra and “plication” (tucking or tightening) the bladder neck to help with urinary control [11][12].
  • Genital Reconstruction: This technique focuses on rebuilding the external vulvar area and has been shown to achieve good urinary control in 60-80% of cases [13][14].

Timing of Treatment

While surgery can be successful at any age, even in adulthood, most experts recommend performing the primary repair during infancy or early childhood (typically between 6 months and 2 years of age) [1][10]. Early surgery allows the child to grow and develop with normal anatomy before the age of toilet training, which can be beneficial for both physical and psychological health [15][10]. For some children with severe cases, a second procedure to specifically tighten the bladder neck may be needed later when they are old enough to participate in potty training [16][17].

Common questions in this guide

When is the best time to have isolated epispadias surgery?
Most experts recommend performing the primary surgical repair during infancy or early childhood, typically between 6 months and 2 years of age. Early surgery allows the child to heal and develop normal anatomy before they begin toilet training.
What is the Modified Cantwell-Ransley technique?
The Modified Cantwell-Ransley technique is a common and reliable surgical approach for boys with epispadias. The surgeon carefully moves the urethral tissue to the bottom side of the penis, which helps straighten it and places the urethra in its natural position.
How is epispadias treated in girls?
Surgery for girls is usually a single-stage procedure that repairs the cleft urethra, split clitoris, and labia. Surgeons use techniques like sub-symphyseal repair or genital reconstruction to improve urinary control and restore external anatomy.
Why do surgeons use a tunica vaginalis flap during epispadias repair?
Surgeons use a tunica vaginalis flap to prevent fistulas, which are small holes where urine unintentionally leaks after surgery. This technique wraps a thin layer of healthy, blood-rich tissue around the new urethral tube to create a waterproof protective seal.
Will my child need a second surgery for epispadias?
While the primary repair is done in infancy, some children with severe cases may need a second procedure later. This often involves a bladder neck reconstruction to tighten the bladder opening, which helps with urinary control once they are old enough to potty train.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Which technique—Modified Cantwell-Ransley or Complete Penile Disassembly—do you have the most experience with, and why do you prefer it for my child?
  2. 2.Will you be using a tunica vaginalis flap or another protective tissue layer to reduce the risk of a fistula (leak)?
  3. 3.How do you plan to address the upward penile curve (chordee) to ensure the correction is permanent?
  4. 4.For a girl, do you recommend a sub-symphyseal or genital reconstruction approach, and what are your typical continence success rates for each?
  5. 5.How will you determine if my child’s bladder is ready for a bladder neck reconstruction during this surgery?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (17)
  1. 1

    A Rare Case of Isolated Male Epispadias.

    Shehzad D, Shehzad M, Mutaal A

    Cureus 2023; (15(9)):e46160 doi:10.7759/cureus.46160.

    PMID: 37905290
  2. 2

    Modified Cantwell-Ransley repair for isolated continent epispadias in adult: Our experience.

    Gite VA, Jain HM, Bote SM, Nikose JV

    Indian journal of plastic surgery : official publication of the Association of Plastic Surgeons of India 2017; (50(1)):68-73 doi:10.4103/ijps.IJPS_243_16.

    PMID: 28615813
  3. 3

    Results of Epispadias Repair Using the Modified Cantwell-Ransley Technique.

    Bar-Yosef Y, Sofer M, Ekstein MP, et al.

    Urology 2017; (99()):221-224 doi:10.1016/j.urology.2016.07.018.

    PMID: 27450348
  4. 4

    Complete penile disassembly in epispadias repair.

    Acimi S, Acimi MA

    International urology and nephrology 2019; (51(4)):579-583 doi:10.1007/s11255-019-02106-4.

    PMID: 30796727
  5. 5

    Redo surgery to improve urinary function, sexual function and cosmesis in male patients with exstrophy-epispadias complex complications. Technical principles and pearls based on case scenarios.

    Pippi Salle JL, Romao RL, Chua M

    Journal of pediatric urology 2024; (20 Suppl 1()):S26-S34 doi:10.1016/j.jpurol.2024.06.004.

    PMID: 38944626
  6. 6

    Application of Tunica Vaginalis Flap for Epispadias Repair in the Epispadias-Exstrophy Complex.

    Sholklapper T, Crigger C, Morrill C, et al.

    Urology 2023; (171()):190-195 doi:10.1016/j.urology.2022.10.015.

    PMID: 36336142
  7. 7

    The Tunica Vaginalis Flap as an Adjunct to Epispadias Repair: A Preliminary Report.

    Lue K, Gandhi NM, Young E, et al.

    Urology 2015; (86(5)):1027-31.

    PMID: 26341573
  8. 8

    Epispadias repair with tunica vaginalis flap.

    Zee RS, Makari JH, Ferrer F, Herndon CDA

    Journal of pediatric urology 2017; (13(5)):523-524 doi:10.1016/j.jpurol.2017.05.023.

    PMID: 28689649
  9. 9

    Female Epispadias Presenting as Urinary Incontinence.

    Jonuzi A, Popovic N, Zvizdic Z, et al.

    APSP journal of case reports 2017; (8(2)):10 doi:10.21699/ajcr.v8i2.548.

    PMID: 28401037
  10. 10

    Isolated female epispadias: A rare case report and surgical outcome.

    Nakka S, Dalvi A, Save M, et al.

    Urology case reports 2026; (67()):103472 doi:10.1016/j.eucr.2026.103472.

    PMID: 42164621
  11. 11

    Sub-symphyseal combined paraurethral flap and bladder neck plication for repair of isolated female epispadias.

    Hammouda HM, Abelgawad AM, Mohamed N, et al.

    Journal of pediatric urology 2026; (22(1)):105680 doi:10.1016/j.jpurol.2025.11.018.

    PMID: 41421935
  12. 12

    Single-stage Female Epispadias Repair by Combined Infrasymphyseal Bladder Neck Plication and Urethrogenitoplasty: A Novel Technique.

    Yadav SS, Agarwal N, Kumar S, et al.

    Urology 2017; (100()):240-245 doi:10.1016/j.urology.2016.09.002.

    PMID: 27639793
  13. 13

    Long-term follow-up after traditional versus modified perineal approach in the management of female epispadias.

    Alyami F, Fernandez N, Lee L, et al.

    Journal of pediatric urology 2017; (13(5)):497.e1-497.e5 doi:10.1016/j.jpurol.2017.02.012.

    PMID: 28392008
  14. 14

    Primary female epispadias: Perineal approach or Kelly repair?

    Leclair MD, Faraj S, Villemagne T, et al.

    Journal of pediatric urology 2018; (14(1)):33-39 doi:10.1016/j.jpurol.2017.08.017.

    PMID: 29426576
  15. 15

    Psychiatric morbidity in bladder exstrophy-epispadias complex: A systematic review with a population-based case-control study.

    Kymäläinen E, Pakkasjärvi N, Pape B, et al.

    Journal of pediatric urology 2026; (22(3)):105795 doi:10.1016/j.jpurol.2026.105795.

    PMID: 41719822
  16. 16

    Bladder Neck Surgery is not Routinely Needed to Achieve Urinary Continence in Patients with Primary Epispadias.

    Mariotto A, Keene DJ, Alshafei AR, et al.

    Journal of pediatric surgery 2024; (59(6)):1182-1185 doi:10.1016/j.jpedsurg.2023.12.017.

    PMID: 38195356
  17. 17

    Male epispadias repair: Outcomes at three sites prior to the establishment of a multi-institutional collaboration.

    Weiss DA, Lee T, Roth EB, et al.

    Journal of pediatric urology 2024; (20(3)):408.e1-408.e6 doi:10.1016/j.jpurol.2024.02.013.

    PMID: 38408877

This page provides educational information on surgical strategies for isolated epispadias. Always consult a pediatric urologist specialized in BEEC for personalized treatment recommendations for your child.

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