RU2252714C1 - Surgical method for treating urethra stricture - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves excising stenosed urethra segment. Urethra segment is built from transplant. The transplant is cut out as flap from urinary bladder wall on vascular pedicle. A sagittally upward step is done at a distance greater than defect length from urinary bladder neck with width equal to urethra perimeter. Pelvic diaphragm orifice allowing the urethra to pass through is widened. The flap is introduced onto perineum through the built tunnel. Proximal portion of the flap is deprived of mucous layer in forming its pedicle. An opening is formed in the flap pedicle. Proximal urethra portion is brought out through the opening. Tube is formed from the flap. Oblique anastomosis are built between the tube and the distal and proximal urethra portions.

EFFECT: enhanced effectiveness in removing defects of any length at any urethra segment.

9 dwg

Description

The invention relates to medicine, the section of urology, surgery of the urethra and can be used as a method of surgical treatment of defects of the urethra of a large extent by replacing the affected urethra with a homograft.

There are several methods for surgical treatment of urethral strictures, which can be classified as follows.

I radical - these include operations - urethral resection according to Marion-Holtsov, Rusakov, Solovov, Johanson's operation [6], [2], [3], [13], [8].

II palliative - sewage according to Vishnevsky, tunneling according to Fronstein, bougieurage.

By the nature of the execution:

I - constricting - application of an urethral anastomosis ″ end to end ″ (these are operations by Rusakov, Holtsov, Solovov) [6], [2], [3], [13], [8].

II - replacement, in which skin grafts are used as a graft (Johanson, Frumkin operation, Karpukhin’s technique) or a “free” mucosal tissue site, usually from the mucous membrane of the cheek, without a vascular pedicle [1], [6], [5], [ 2], [13].

Recently, two-stage operations of the “mixed” type, based on recanalization and partial replacement by the skin, have been proposed [4], [7].

According to some sources, the complication rate is from 10% to 50%.

The disadvantages of all previously available techniques were:

with constricting operations - deformation and curvature of the penis, especially with erection, restenosis;

during substitution - frequent fistulas, restenoses, mismatch of the epithelial surface of the graft with urethral epithelium (hair growth in the urethral lumen, maceration and ulceration of the skin, mucosal rejection with free plastic).

The results of two-stage operations are somewhat better, but also have complications, and the disadvantage is the duration of treatment (up to 1 g or more) [14], [15].

We first proposed a method for treating urethral strictures, including using a tongue-like flap from a solid bladder wall on a feeding vascular pedicle as a homograft, a length of a larger replaceable urethral defect, a width equal to the perimeter of the urethra, removing the flap to the perineum through a natural opening of the external sphincter of the urethra holes in the leg of the flap and the removal through it of the proximal section of a healthy urethra, the formation of a tube on the stent from the mucosa of the flap, avedennom from the bladder, by the length corresponding to the damaged portion of the urethra, followed by the application of oblique anastomoses between the graft formed from a tube and the distal and proximal urethra Department of Health.

The following is a detailed description of the proposed methodology. The initial pathological condition is presented in figures 1, 2, where 1 is the bladder, 2 is the proximal section of a healthy urethra, 3 is a section of stenosis, 4 is the distal section of a healthy urethra.

Tissues are cut through a lower midline incision. The retroperitoneal bladder, symphysis and pubic joint bones (medial part of the upper branch of os pubis) are isolated. Departing from the neck of the bladder, a tongue-like flap of greater length is cut sagittally upward than the length of the replaced defect of the urethra, a width equal to the perimeter of the urethra, while maintaining the branches of the lower bubble arteries. Figure 3 pointer 5. Demucose in the proximal part of the flap along the length of about one and a half lengths of a healthy section of the proximal urethra. This part of the flap will be the feeding leg and pass through the thickness of the muscles of the pelvic diaphragm. Figure 4 pointer 8. To facilitate access to the neck of the bladder, the prostatic urethra and the external sphincter of the bladder, perform subperiosteal osteotomy of the upper branches of the pubic bone with symphysis, departing 2.5-3 cm from the midline. Figure 3 pointer 6. The lower part of the pubic joint 0.5-1 cm wide, depending on age, is retained. Thus, an exit was made to the pelvic diaphragm and the anterior part of the prostatic urethra through the prevesical tissue and venous plexus. Next, the tissue to the urethra is dissected through the midline sagittal section along the midline above the stenotic portion of the urethra. The urethra is mobilized, the affected area is resected within healthy tissues. Resection of the urethra is made oblique cut outwards. Figure 3 pointer 7. The proximal part of the urethra is mobilized bluntly to the bladder neck, in order to avoid damage to nerves and vas deferens, especially in the posterior surface of the prostatic region.

The natural opening in the diaphragm of the pelvis, through which the urethra passes, and the external sphincter of the bladder bluntly expand. A bladder flap is made through the resulting tunnel. To do this, the flap is folded and held freely down without rotation and significant tension. Thus, the proximal urethra is located after the flap has been removed to the perineum posterior to the flap, the “mucous” part of the graft, from which the tube and subsequent anastomoses will be formed, is facing anteriorly. Figure 5. In order to transpose, in the mucous part of the flap at the level of the lower edge of the prostate, a hole is stupidly performed, Fig. 5 pointer 9, through which the proximal urethra is brought to the front surface of the flap. 6. The muscle mass of the flap, grasping the urethra after transposition, is fixed with sutures to the adjacent muscles of the perineum in order to avoid squeezing the urethra in the subsequent urination. A stent is inserted from the bladder through the proximal urethra, on which a tube is formed from the mucous part of the flap. 7, pointer 10. After that, the stent is passed through the distal urethra and removed through the meatus of the penis. The stent remains for 7-10 days after surgery.

Impose oblique anastomoses between the formed tube and the distal and proximal urethra. Fig.8, Fig.9. The integrity of the muscles and skin of the perineal section is restored. Epicystostomy is performed from the midline incision, and a bladder defect formed after the flap is taken is sutured to the epicystostomy. Part of the symphysis after osteotomy is returned to the place and fixed with a suture or knitting needle, depending on age. The periosteum is restored. The lower middle incision is sutured in layers before drainage.

Example. Patient S., aged 14, was admitted on September 17, 2003 to the surgical department of the CSTO in Ulyanovsk with complaints of fever, difficulty in painful urination, clouding, and an unpleasant smell of urine. Deterioration began to be noted 1 month before treatment. The phenomena of paradoxical ischuria (discharge of urine dropwise) 2 days before hospitalization.

On photographs and urethroscopy, a stricture of the urethra of considerable length from the bulbar to the prostatic sections is noted. Patency is almost completely absent. Figure 1, 2. On the day of admission, a puncture epicystostoma is applied.

An operation was performed on 04.17.2003, the development of the urethra, a resection of the stenotic area within healthy tissues. After further examination and preparation on September 17, 2003, the operation was performed for the first time according to the methodology provided.

″ September 17, 2003 OPERATION PROTOCOL

Revision, resection of the membranous and bulbar sections of the urethra, followed by plasty of these sections with a bladder from the bladder on the feeding leg.

Under endotratracheal anesthesia, in the position of the patient on the back, the lower mid-section of the urinary bladder is retroperitoneally isolated. A detrusor-mucous flap up to 14 cm long and 4 cm wide was cut from the bladder along its front surface with preserving vascular architectonics. The mucous part of the wall was removed from the base of the flap, 3-4 cm long (demucosis was performed). The flap is thrown back to the neck of the bladder. The vascular leg is 3 cm. In order to facilitate access to the bladder neck, posterior urethra and pelvic floor, a subperiosteal osteotomy of the pubic joint was performed with mobilization of the medial sections of the tendons of the rectus muscles of the abdomen 3 cm on each side and preservation of the lower symphysis. The neck of the bladder is mobilized. The exit to the pelvic floor. On the perineum, a cut from the scrotum to the anus, dissected tissue. The urethra is mobilized, its prostatic section to the bladder is isolated. The bleeding is moderate, hemostasis, the volume of blood loss is about 400 ml. Resection of the stenotic section of the urethra is oblique, within the limits of healthy tissues. The cystic flap is inserted through the opening of the external urethral sphincter.

A transposition of the flap and urethra was performed: for this purpose, a hole was made in the mucous part of the flap at the level of the prostate gland through which the proximal urethra was inserted. After this, the urethral tube is formed from the mucous part of the flap, oblique proximal urethro-urethroanastomosis is placed on the stent. Next, the newly formed urethra is brought to the distal section. Imposed oblique distal urethro-urethroanastomosis. The detrusor part of the flap is fixed to the muscles of the perineum. The pelvic ring is restored. The bladder is sutured leaving a stoma. Performed a tamponade of the anterior bubble vein plexus with a hemostatic sponge. A fragment of the symphysis is returned to its place, the periosteum is sutured with interrupted sutures. Drainage through contraception in the right inguinal-iliac region to the paravesical space. Sutures on the subcutaneous tissue and skin ″.

The stent was removed 10 days after surgery. Epicystostoma - on the 14th day.

At discharge: urination independent, urine holds. There are no phenomena of enuresis. In the pictures, the urethra is passable. With uroflowmetry, there is no data for infravesical obstruction. Fig.9.

Pathological conclusion: the stenotic area extends from the bulbar to the prostatic sections, a fragment of the urethra with severe fibrosis, hypertrophy of the muscle membrane. Part of the vessels with sclerosis of the walls and obliteration of the lumen.

This technique allows you to eliminate defects of any length and in any area. The extensibility of the detrusor and the bladder mucosa is similar to the extensibility of the urethra and cavernous bodies, which does not lead to deformation of the penis during erection, which is possible with other methods. The homogeneity of the mucous membranes of the urethra is preserved, there are no complications inherent in skin grafts (hair growth, fistulas). Preservation of the feeding vessels of the flap legs provides good trophic anastomoses and prevents the development of fistulas, contributes to a good graft engraftment. Quick recovery and reduced hospitalization.

Sources of information

[1] ″ Restoration of the urethra using a homograft ″. V.T. Karpukhin, 1966, Moscow.

[2] ″ Stricture and obliteration of the urethra ″. V.I.Rusakov, publishing house of the Rostov University, 1987

[3] ″ Urethral stricture ″. V.I. Rusakov, Moscow, 1962

[4] ″ Two-stage urethroplasty for complex and complicated urethral strictures ″. K.K.Karimbaev, Urology and Nephrology, Moscow, 1999, No. 5.

[5] ″ Surgery of the urethra ″. V.I. Rusakov, Moscow, 1991

[6] ″ Urethral stricture in children. ″ V.V.Nikolaev, E.A. Stepanov, Moscow, 1998

[7] ″ Modern treatments for extended and complicated urethral strictures ″. KK Karimbaev, Abstract of a doctoral dissertation, Moscow, 2002

[8] ″ Surgical treatment of post-traumatic and recurrent urethral strictures in men. ″ R.I.Safiullin, Abstract of a candidate dissertation, Ufa, 2000

[9] ″ Treatment of closed injuries and post-traumatic urethral strictures ″. VB Muravyov, “Urology and Nephrology,” Moscow, 1991, No. 2.

[10] ″ Treatment of posterior urethral obliteration in men. ″ MF Trapeznikova, “Urology and Nephrology”, Moscow, 1997, No. 6.

[11] ″ Surgical treatment of post-traumatic strictures and obliteration of the posterior urethra ″. VGGnilorybov, ″ Urology and Nephrology ″. Moscow 1991, No. 6.

[12] ″ Proximal urethral strictures in men. ″ O.B. Laurent, ″ Urology and Nephrology ″. Moscow. 1991, No. 6.

[13] ″ Pediatric Surgery ″. K.U. Ashkrovt, vols. 2-3, St. Petersburg, 1997.

[14] ″ Operational Urology ″, ed. Lopatkina N.A., Moscow, 1986

[15] ″ Guide to Clinical Urology ″, ed. A.Ya. Pytelya, Moscow, 1970

Claims (1)

A method for surgical treatment of urethral strictures, including resection of a stenotic urethral region, forming an urethral region from a transplant, characterized in that the transplant is cut out in the form of a tongue-like flap from the wall of the bladder on the vascular pedicle, departing from the bladder neck sagittally upward longer than the length of the defect, and with a width equal to the perimeter of the urethra, the opening in the diaphragm of the pelvis through which the urethra passes stupidly widens, a flap of the bladder to the perineum is brought out through the formed tunnel, the proximal part of the flap is demucozed, forming its leg, after which a hole is made in the flap leg through which the proximal urethra is removed, then a tube is formed from the flap and oblique anastomoses are placed between the formed tube and the distal and proximal parts of the urethra.

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