RU2284767C1 - Method for surgical treatment of complicated forms of stem hypospadias - Google Patents

Abstract

FIELD: medicine, urology.

SUBSTANCE: it is necessary to substitute the lacking part of urethra with a tube formed out of two rectangular skin fragments cut upon penile ventral surface and upon anterior scrotal surface followed by isolating penis from scrotum in 2-3 mo. Moreover, one should make two parallel incisions from atrioventricular groove up to the level of anterior urethral opening. Incisions should be connected being under meatus to form a fragment. Due to leaving a distance against penoscrotal angle being equal to penile length against external urethral opening up to scrotum one should form a fragment upon anterior scrotal surface being correspondent by its value to penile fragment. Then one should connect parallel scrotal and penile incisions, dissect the developed rectangular fragment in area of penoscrotal angle, perform urethroplasty by suturing the tops and lateral surfaces of the fragments, suture external edges of penile and scrotal cutaneous wounds.

EFFECT: higher efficiency of therapy.

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Description

The invention relates to medicine and will find application in urology, in particular in the treatment of complicated forms of hypospadias.

Hypospadias is a congenital malformation of the external genital organs of boys, characterized by the absence of a distal part of the urethra and the corresponding dystopia of the meatus (P.P. Prodeus, O.V. Staroverov: Hypospadias - M., 2003, p. 7).

According to domestic and foreign authors, hypospadias occurs in one of 300-400 newborn boys. Correction of this anomaly presents for many doctors great, and sometimes insurmountable difficulties (V.I. Rusakov: Treatment of hypospadias. - Rostov-on-Don, 1988, p.3).

Complicated hypospadias include all forms of hypospadias after unsuccessful operations undertaken to restore the urethra. It is necessary to restore the missing part of the urethra. When drawing up a treatment plan for such patients, the nature of previous operations, their complications and consequences should be taken into account (V.I. Rusakov: Treatment of hypospadias. - Rostov-on-Don. 1988, p. 73).

Studies of medical and patent literature have identified various methods of treating complicated forms of hypospadias.

In the atlas of F. Khinman: Operative urology (Translated from English, edited by Yu.G. Alyaev and V. A. Grigoryan, Moscow, 2001, p. 154-155) urethral plastic with a ventral flap is described (Tirsch-Duplay operation), carried out as follows: "On the ventral surface of the trunk of the penis, lines of 2 parallel sections are applied with the border of the distoped external opening of the urethra. The head is cut along the outlined lines, forming a V-shaped and lateral flaps. The distal end of the ventral flap is mobilized and cut in the longitudinal direction in order to stitch the V-shaped flap of the head with chrome catgut thread 6-0 to it, with the skin hooks lift the edges of the ventral flap and sew them in 3-4 places, after which the edges of the flap are connected along the entire length with a continuous intradermal suture with 6- 0. The lateral flaps of the head are connected with a synthetic absorbable suture, additional knotted sutures are superficially applied with a thin thread. Only in an extreme case, a laxative incision is made on the dorsal surface, the defect area is closed with a split skin graft. The subcutaneous tissue is compared with several sutures, the skin is connected with continuous intradermal or interrupted sutures, while the suture should pass away from the midline.

The disadvantage of this method is the possible shortage of plastic material that occurs after urethroplasty, and therefore the frequency of complications of the postoperative period increases: suppuration of the wound, the formation of urethral fistulas, urethral stricture.

In the work of R. A. Burger, S. C. Muller, H. El-Damanhouri et al. The buccal mucosal graft for urethral reconstruction // J. Urol. - 1992. - Vol. 147. - P.662 describes a method for surgical treatment of complicated forms of hypospadias using a free flap cut from the cheek mucosa. The flap was used in the form of a tubular flap, which replaced the missing segment of the urethra with anastomosis end to end, or of the patch, when it was possible to save the front of the urethra, and the cut back was replaced by the cut flap (as the so-called onlay operations).

The disadvantage of this method is the use of two urethral anastomoses in these operations, which leads to a high risk of formation of urethral strictures.

In the work of V. I. Rusakov, “Treatment of hypospadias” (Publishing House of Rostov University, 1988, pp. 60-64), a method for treating complicated forms of hypospadias is described, which is carried out as follows: two parallel incisions are made on the ventral surface of the penis. The width of the flap is determined in accordance with the age of the patient, the size of the penis and urethra. 2-3 mm below the external opening of the urethra, the sections are connected. Two strips of skin up to 0.2-0.3 cm wide are excised on the lower surface of the glans penis - wounds are formed that are a continuation of the wounds of the lower surface of the penis. In the distal section, the incisions are somewhat closer (up to 0.5-0.8 cm), which is necessary for the formation of the external opening of the urethra. Having departed from the penoscrotal angle by a distance equal to the length of the penis from the external opening of the urethra to the scrotum, a rectangular flap is cut out on the front surface of the latter, in size and shape corresponding to that on the penis. The penis is brought closer to the front surface of the scrotum so as to match the cut flaps. The nodal sutures staple the edges of the transverse wounds of the penis and scrotum. Next, the edges of the formed rectangular flaps are sutured. Then, the outer edges of the skin wounds of the penis and scrotum are sutured.

After 2-3 months, the penis is released from the scrotum - the final stage of the operation.

An oval incision, departing 1-1.5 cm from the scars formed after urethral plastic surgery, cut through the skin of the scrotum. In front, the scrotum skin is dissected at the glans penis. The penis is partially acute, but mostly blunt, isolated from the scrotum, along with the scrotal skin graft that has grown together with it, which has formed the urethra, and the scrotal tissues adjacent to it. The penis is released. After hemostasis, wounds on the penis and scrotum are sutured with interrupted sutures.

The disadvantages of this method are: a high risk of trophic disorders in the cut off scrotum flap at the final stage of the operation due to the complete intersection of blood vessels feeding the flap; deformation of the penis (the formation of the so-called cutaneous "beard").

This method, as the closest in its technical essence, is taken as a prototype.

The aim of the invention is the prevention of circulatory disorders in a detached skin flap of the scrotum, a cosmetic effect.

This goal is achieved by continuing parallel sections from the ventral surface of the penis to the scrotum, followed by excision of the formed rectangular skin flap not used in urethroplasty.

The method is as follows: on the ventral surface of the penis make two parallel incisions from the coronary sulcus to the level of the external opening of the urethra. Two strips of skin up to 0.2-0.3 cm wide are excised on the lower surface of the glans penis - wounds are formed that are a continuation of the wounds of the lower surface of the penis. In the distal section, the incisions are somewhat closer (up to 0.5-0.8 cm), which is necessary for the formation of the external opening of the urethra. 2-3 mm below the meatus, the sections are connected. Having departed from the penoscrotal angle by a distance equal to the length of the penis from the external opening of the urethra to the scrotum, a rectangular flap is formed on the front surface of the latter, the largest corresponding to that on the penis (figure 1). Then parallel sections on the penis and scrotum are connected, the resulting rectangular flap in the area of the penoscrotal angle is excised (figure 2). By stitching the tops of the flaps and then the lateral surfaces, urethroplasty is performed on a previously inserted urethral catheter. Next, the outer edges of the skin wounds of the penis and scrotum are sutured, and the external suture is continuous up to the penoscrotal angle (Fig. 3).

After 2-3 months, the final stage of urethroplasty is performed, consisting in the selection of the penis from the scrotum in a sharp and blunt way along with the scrotal skin graft that has fused with it up to the penoscrotal angle (Fig. 4).

This technique allows you to maintain the integrity of the blood vessels that feed the cut off scrotum flap; good cosmetic result of the operation.

Example 1

Patient S., 15 years old, was admitted with complaints of abnormal development of the urethra. Previously, the patient underwent 5 operations for the stem form of hypospadias without effect.

The general condition of the patient is satisfactory. The organs of the scrotum and penis are developed normally. On the ventral surface of the penis - postoperative scars after previous operations. Penile curvature is not observed. The external opening of the normal size urethra is 3.0 cm from the penoscrotal angle.

Clinical diagnosis: complicated form of stem hypospadias.

The patient underwent surgery - urethroplasty with a scrotal skin graft. Two parallel incisions were made on the ventral surface of the penis from the coronary sulcus to the level of the external opening of the urethra. Two strips of skin up to 0.2-0.3 cm wide are dissected on the lower surface of the glans penis - wounds are formed that are a continuation of the wounds of the lower surface of the penis. In the distal section, the sections are somewhat close (up to 0.5-0.8 cm). 2-3 mm below the meatus, the sections are connected. Having departed from the penoscrotal angle by a distance equal to the length of the penis from the external opening of the urethra to the scrotum, a rectangular flap is formed on the front surface of the latter, the size of which corresponds to that of the penis. Then parallel sections on the penis and scrotum are connected, the resulting rectangular flap in the area of the penoscrotal angle is excised. By stitching the tops of the flaps and then the lateral surfaces, urethroplasty is performed on the urethral catheter previously inserted through the external opening of the urethra into the bladder. Next, the outer edges of the skin wounds of the penis and scrotum are stitched.

On the 7-8th day after the operation, skin sutures were removed. Wound healing proceeded without inflammatory complications.

The patient was again hospitalized after 2 months and he underwent the second stage of the operation - the release of the penis from the scrotum. An oval incision, retreating 1-1.5 cm from the scars formed after urethral plastic surgery, cuts the skin of the scrotum. The penis is isolated from the scrotum, together with the scrotal skin flap that has grown together with it, which has formed the urethra, and the scrotal tissues adjacent to it. The penis is released. After hemostasis, wounds on the penis and scrotum are sutured with interrupted sutures. In view of the preservation of blood circulation of trophic disorders, a cutaneous flap of the scrotum was not observed.

In the distant period, 12 months after the second stage of the operation, a good postoperative cosmetic effect was noted. There is no curvature of the penis during erection. Urination in the urethra is free, with a good stream.

Example 2

Patient K., 10 years old, was admitted with complaints of an abnormal location of the external opening of the urethra, slight curvature of the penis during erection in the area of the coronary sulcus, urination with a thin, intense stream.

From the anamnesis it was found that the patient had 6 operations before entering the clinic for this pathology: straightening the penis, urethroplasty of various modifications without effect.

Objectively: the general condition of the patient is satisfactory. The organs of the scrotum and penis are developed normally. The penis during artificial erection is bent downward in the coronal groove. The meatus is narrowed to 3 mm in diameter, located proximal to the coronal groove by 1.0 cm.

Clinical diagnosis: complicated form of stem hypospadias.

At the first stage, the patient underwent surgery - straightening of the penis by excision of the paraurethral scars, meatotomy with the movement of the external opening of the urethra in the proximal direction. It began to be located at a distance of 3.5 cm from the penoscrotal angle.

After 3 months, the patient underwent the second stage of the operation - urethroplasty according to the proposed technique. The postoperative period was uneventful. After removal of the urethral catheter, urination recovered from the formed urethra.

The final stage of the operation was performed after 2 months.

The penis was isolated from the scrotum along with the scrotal skin graft fused with it up to the penoscrotal angle. In view of the preservation of the vessels feeding the cut flap, no trophic disorders of the flap were observed in the immediate postoperative period.

12 months after the last stage of the operation, a good cosmetic effect was noted. Urination through the urethra without straining, with a good stream.

Thus, the advantages of the proposed method compared to the prototype are that it allows you to maintain total blood circulation in a cut off scrotum flap when the penis is cut off from the scrotum, due to which there are no trophic disorders of the flap, and also provides the best cosmetic result of the operation in the long term.

Claims (1)

A method for the surgical treatment of complicated forms of stem hypospadias, including replacing the missing part of the urethra with a tube formed of two rectangular skin flaps cut on the ventral surface of the penis and on the front surface of the scrotum, and after 2-3 months the penis is isolated from the scrotum, characterized in that first, two parallel incisions are made on the ventral surface of the penis from the coronary sulcus to the level of the external opening of the urethra, below the meatus, the incisions are connected, forming a straight line the angular flap, then departing from the penoscrotal angle by a distance equal to the length of the penis from the external opening of the urethra to the scrotum, form a rectangular flap on the front surface of the scrotum, the size corresponding to that on the penis, then parallel sections on the penis and scrotum are connected and dissected the resulting rectangular flap in the area of the penoscrotal angle, then urethroplasty is performed by stitching the tops and side surfaces of the flaps of the ventral surface of the penis and days surface of the scrotum, then sutured the outer edges of skin wounds of the penis and scrotum, after 2-3 months of release penis scrotum.

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