RU2454945C1 - Method of skin flap formation in plasty of urethra caused by "distal" hypospadias by kravtsov ya-1 - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to urology, children's surgery. On volar surface of penis longitudinal ribbon-like continuous flap of two parts is marked. Fixed part of flap is narrow skin strip on urethral track from head to meatus. Part of flap is separated from cavernous bodies without cutting off in distal part. Wall of urethra is created from bridge-shaped flap, bending it in half in the area of future frenulum. First part of flap is sewn with "urethral strip", skin wound - with second part of bridge-shaped flap.

EFFECT: method makes it possible to simultaneously perform plasty of urethra, ensures bringing meatus on penis head, eliminates risk of skin flap necrosis and formation of strictures, fistulas and stenosis of urethra.

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Description

The invention relates to medicine, namely to urology, andrology and pediatric surgery, and is intended for urethral plastic surgery in the surgical treatment of distal hypospadias.

In the arsenal of the urologist there are a number of ways to restore the missing part of the urethra: meato- and glanuloplasty, plastic according to Matthew’s method, according to Hodson XX, mobilized flap from the inner sheet of the foreskin (Duquette operation), a flap from the external leaf of the foreskin (Sandoli operation), perimetal Hinderer flap, skin graft (Devin-Horton operation), a graft from the mucous membrane of the cheek, bladder (Rudin, Yu.E. Treatment of distal hypospadias in children Yu.E. Rudin, E.B. Alekseev. // Urology and Nephrology . - 1997 . - No. 3. - S.41-44).

Correction of the anterior form of hypospadias with the location of the hypospadias meatus on the glans penis and in the area of the coronary sulcus is made using MAGPI technology. An indication for the use of this technique is the location of the hypospadias meatus in the region of the coronary sulcus or glans penis without ventral deformity of the latter. The operation begins with a bordering incision around the glans penis, and on the ventral surface, the incision was performed 8 mm proximal to the hypospadias meatus. After mobilization of the skin of the penis, a longitudinal incision is made along the scaphoid fossa through the posterior wall of the meatus. The incision is made deep enough to cross the tissue bridge, located between the hypospadias of the meatus and the distal edge of the scaphoid fossa and the deflecting stream when urinating ventrally. The dorsal meatal margin takes a V-shape and thereby eliminates any meatal narrowing. The wound formed on the ventral surface is sutured with two transverse sutures. Thus, the ventral surface becomes smooth and the ventral deviation of the urine flow is eliminated. For the production of glanuloplasty, a sharp single-tooth hook is used, with which the skin edge proximal to the hypospadias meatus rises towards the head so that the ventral edge of the surgical wound resembles an inverted letter V. The lateral edges of the wound on the head are sutured with three U-shaped sutures without tension. A wound defect is closed by the remains of mobilized skin (AK Fayzulin. One-stage correction of hypospadias in children: Author. Diss. Cand. Medical Sciences. - M., 1995. - p.4).

The disadvantage of this method of MAGPI technology is that the opening of the neourethra is not completely displayed on the head. The method is applicable only to limited forms of distal hypospadias - capitate and coronary. In the postoperative period, strictures of the created urethra are also observed, which are formed as a result of cicatricial degeneration of its fragment, where a wide mobilization of the skin flap is applied, leading to local tissue ischemia. Urethral stenosis, in turn, leads to impaired passage of urine and the development of a chronic inflammatory process in the urinary tract. Most often in the immediate postoperative period, fistula of the urethra and divergence of the urethral suture occur.

As a prototype, the method of surgical treatment of the distal stem form of hypospadias according to Matthew, an inverted flap of the skin of the trunk of the penis, was selected. (Hinman F. Operational Urology: Atlas: Transl. From English. - M.: GEOTAR-MED, 2003. - p.138-139).

For children with distal hypospadias: subvenous and stem forms, the operation of the plastic of the urethra is shown with an inverted flap of the skin of the trunk of the penis according to the method of Matthew. The urethra is formed by stitching together a narrow longitudinal flap of the skin of the "urethral strip" and a wide skin flap of the ventral surface of the shaft of the penis, inverted in the direction of the head. The method begins with marking the skin with a marker in a state of artificial erection, skin incision with thorough hemostasis, using microsurgical instruments and optical magnification using a binocular magnifier.

Operation Matthew consists of the following steps:

1. Marking the flap.

2. Mobilization of a wide proximal flap site.

3. Mobilization of the "wings" of the head.

4. Urethral plastic surgery with an inverted flap of the skin of the trunk of the penis.

5. Formation of the urethra by a continuous suture.

6. Mobilization of the preputial sac. Covering the urethra with flaps of the meaty membrane.

7. A longitudinal laxative incision of the foreskin along the dorsal surface.

8. Wound closure.

The created urethra is additionally covered with rags of the fleshy membrane of the foreskin, laid on the line of sutures in a cross direction. This technique allows you to create a short section of the urethra with the formation of the external opening of the urethra at the top of the head, with good cosmetic and functional results.

However, the following disadvantages are noted in the described surgical access. This operation has contraindications. It is inappropriate to use the inverted flap technique in cases of dysgenetically altered (thinned and sedentary) skin of the ventral surface of the penile shaft, especially in the area of the external opening. The method is limited to the distal stem form of hypospadias. In the presence of a pronounced cicatricial chord, glanuloptosis, Matthew’s operation does not allow the correction of deformation, since the bed of dysplastic urethra and chord that supports curvature is preserved. To eliminate skin deficiency after flap cutting out, it is necessary to move the skin from the dorsal surface of the penis, which sometimes leads to tension of the skin sutures and the need for free skin grafting. Especially significant is the problem of skin deficiency of the penis during repeated surgical interventions for hypospadias and after circumcision, when the foreskin is missing. In these cases, they suggest using free flaps from the mucous membrane of the cheek, lips, which causes additional surgical trauma. The scarring zone when moving the skin grafts is located both on the volar (hardly visible in cosmetic terms) region, and on the dorsal surface of the penis. Mobilization of the wings of the head with subsequent suturing over the anastomosis zone also carries the risk of seam divergence, especially in the case of spontaneous erections, and leads to a visual reduction in its size. These factors can contribute to a slower healing of the postoperative wound with the formation of infiltrate. There is a high probability of insufficiency of sutures of the anastomosis of the urethra, necrosis of the skin flap, the formation of a fistula. As a result, some of the patients require repeated surgical interventions for complications (fistula, stenosis) or relapse of hypospadias.

The objective of the invention is to improve the results of surgical treatment of this disease, as well as preventing its recurrence after surgical treatment, to create clear criteria for determining the configuration of a continuous skin flap of the penis during surgical intervention for hypospadias, and to reduce the likelihood of postoperative complications from the wound (skin flap necrosis , the formation of anastomotic insufficiency and the formation of fistulas), increase the functional and cosmetic effects of the operation.

The basis of the present invention is the task of developing an objective, affordable and easily reproducible method of urethral plasty during hypospadias, which eliminates the disadvantages of known methods of plastics, especially the risk of necrosis of the skin flap, followed by the formation of strictures, fistulas, stenosis of the urethra.

The technical result of the invention is the preservation of blood supply to the flap, simplicity and ease of execution without delaying the time of surgery, simultaneous surgery, performed painlessly for children.

The technical result of the invention is achieved by the fact that in the method of urethral plasty the nutrition of the skin flap is preserved, since a continuous ribbon-like flap of the penis "a" voluntary surface is used, and there is no need to separate the skin of the entire surface of the penis, which improves the conditions of wound healing.

The problem is solved as follows.

For surgical treatment of the distal hypospadias, the operative approach is changed using a plastic strip of the skin of the voluntary surface of the penis in the form of a “tape”, by performing two symmetrical surgical incisions along the lateral surfaces of the trunk of the penis, along the border of the ventral and lateral regions, in the longitudinal direction with respect to the trunk. For this purpose, an surgical incision is performed with the distal form of hypospadias so that when cutting the flap does not intersect on the trunk of the penis. Then the lateral incisions are extended to the scrotum, maintaining its continuity in the form of a skin “bridge” between the urethral opening and the scrotum, passing to its middle third (Fig. 1). After performing a skin incision, the edges of the lateral incisions are separated to the sides by 0.5-1.0 cm and the underlying subcutaneous fascia of the tub is dissected in the same direction and so that the “skin bridge” has a wider subcutaneous base, which is then used for interposition between skin seams. Then, a full-layer “skin bridge” is prepared along the entire length from the meatus to the middle third of the scrotum, separating it from the deep fascia and taking it to the holder. The direction of the incisions when cutting out the free part of the skin flap should not be parallel, but conical, with a divergence towards the scrotum (figure 2). At the end of the incision (on the scrotum), angular skin incisions are made at an angle of 80-90 ° in order to subsequently excise the flaps of a triangular shape to prevent the formation of noticeable deformations of the skin of the scrotum in the form of ridges, as well as to lengthen the skin flap. After separation of the skin bridge-like flap with the help of holders, a fold is formed in the transverse direction at the level of the head and the strip of the mucous membrane of the urethral bed and the inner fold of the ribbon-like skin flap are sewn from the meatus to the head. Anastomosis is imposed with single-row absorbable interrupted sutures (polysorb, vicryl, 5-00, 6-00), tying knots in the lumen of the future neourethra. Previously, a Foley catheter, No. 8-12 Fr, is carried out in the bladder, depending on the age of the patient and the diameter of the urethra. After checking the tightness of the anastomosis, sections of the divergence from the subcutaneous layer are additionally stitched with the second row of interrupted sutures. Then they begin to cover the anastomosis zone with a pre-formed excess of subcutaneous fascia in the form of a protruding strip, hemming it with a continuous absorbable suture on both sides of the skin bridge-like flap, under the separated skin of the lateral sections of the penis. In this case, the penis is given a vertical position with its laying on the stomach. Excess skin is excised on the scrotum in the area of the angular incisions, removing triangular flaps of skin on the lateral outer edges of the incisions. After that, skin incisions are sutured on both sides with interrupted absorbable sutures so as to displace the ribbon-like skin flap from the scrotum to the side of the glans penis. As a result of suturing the wound, the suture lines should not overlap each other, between the anastomosis and the line of skin sutures, the subcutaneous fascia is interposed. A bandage is applied to the trunk and the glans penis, leaving only a small opening for the silicone catheter. In the case of the primary operation, an excess of the foreskin in the form of a “hood” is additionally resected; during the second operation, this is not necessary. If the patient has a pronounced cicatricial "chord" that deforms the trunk and causes a noticeable curvature, at the stage of mobilization of the urethra, the strip of the "urethral bed" is separated from the chord by preparation, the chord is excised under the urethra detached in the form of a "bridge", keeping the connection of the urethral site with the skin of the glans penis.

The advantages of the proposed method of plastic urethra are as follows.

First of all, the risk of complete or partial necrosis of an inverted skin flap is reduced, since the connection of the tape-like flap with the skin of the penis both in the distal and in the proximal direction is preserved. In addition, unlike an inverted flap, there is a connection with the subcutaneous fascia, which significantly improves blood circulation to the skin. The conical shape of the mobilized part of the cut flap, its wide base, ensures the preservation of vascular connections with the scrotum. The absence of laxative cuts on the back of the penis narrows the area of tissue scarring. The anastomosis with the "urethral site" is applied under more favorable conditions, since the thickness of the skin flap is increased, fixation of the flap all the way to the lateral incisions relieves the tension of the anastomotic sutures, preventing them from diverging. An important factor in the prevention of seam divergence is the shelter of their subcutaneous fascia, which is provided for by this method. The need for preliminary marking of the flap into 3 sections determines its functional correspondence, in which the first section makes up the neourethra wall, the second section covers the anastomosis line, and the third section provides the nutritional basis of the flap by expanding its base. All of the above, in general, increases the cosmetic effect of the operation, improves the conditions for wound healing. In addition, the method is universal and applicable for all "distal" forms of hypospadias - head, coronary, subvenous, distal stem.

The method is instantaneous, it allows you to immediately straighten the corpora cavernosa and urethral plastic, provides excretion of the meatus on the glans penis. Since skin incisions with this method pass along the lateral parts of the trunk of the penis, the scars will not cause secondary curvature and deformation.

The set of essential features of the proposed method in the available literature is not found.

The invention is illustrated by drawings, where figure 1 shows a diagram of skin incisions with plastic urethra with a longitudinal skin graft in the form of a "bridge"; figure 2 - shows a diagram of the departments of the skin flap in the form of a "bridge"; figure 3 - shows the mobilization of a longitudinal bridge-like flap of the skin; figure 4 shows the final view of the plastic of the urethra with a longitudinal bridge-like skin flap after suturing the wound.

The inventive method is illustrated by the following example.

Patient Z. Sergey, 13 years old. Sick from birth. Operated repeatedly, starting from the age of 3 years, regarding proximal hypospadias and cryptorchidism. He underwent more than a dozen surgical interventions for hypospadias and cryptorchidism. A stepwise correction was performed, including prompt rectification of the penis, Duplay urethral plastic surgery, operations for strictures and fistulas of the urethra. Upon receipt of the diagnosis of hypospadias, keloid scars of the inguinal region, the only testicle on the left. Local status: cavernous bodies are straight, about 4 cm long at rest, there is a micropenis of the type of "hidden" penis. The skin of the penis is scarred as a result of multiple operations. The opening of the neourethra is located in the distal third of the penis, with a diameter of up to 1.2 cm, the distance from the meatus to the apex of the glans penis is 2.7 cm. Under general anesthesia, after parapenal blockade of the nerve trunks, incisions and flap were marked, the length of the non-peeling part of the flap was 2.5 cm. The length of the flap from the urethra to the base was 6.5 cm, the width in the narrowest part (“urethral strip”) was 0.8 cm, the base of the flap was 5.0 cm, the width in the area of the future urethra was 2, 3 cm. The next step is skin incisions: in First, on the glans penis in the area of the urethral strip, two parallel skin incisions with a distance between them of 0.8 cm, a length of 2.5 cm, then we started to cut out a skin flap, starting with a bordering skin incision around the urethral opening, and then in the form two parallel lines with a length of 2.7 cm and a width of 2.3 cm for the formation of neourethra. Subsequently, the incisions were expanded to the base of the flap, at the base of the incisions extended laterally, at an angle of 90 ° towards the edge of the skin flap. After performing the skin incisions, the skin was prepared to prepare the skin of the lateral edges of the incision by 0.5 cm, then the extraction of a full-layer skin median flap along with the subcutaneous fascia began, and the width of the subcutaneous fascial layer exceeded the width of the skin flap by 0.5 cm on both sides. After mobilization of the flap and opening of the urethra, 2.5 cm back from the meatus, a fold of skin of the flap is formed in the transverse direction with two handles of absorbable material. The neourethra were formed in two rows of parallel absorbable sutures, after which the edges of the separated subcutaneous fascia were tucked under the separated flaps of the head, the skin of the flap was stitched with the lateral surfaces of the skin of the penis. Aseptic dressing.

New in the proposed method is that a longitudinal bridge-shaped continuous flap is formed, having two parts: the first (fixed part) is a narrow strip of skin on the urethral path from the head to the meatus, which is not separated from the base, having parallel edges; and the second part, which is separated from the cavernous bodies in the form of a bridge-like strip of skin, starting from the meatus and ending with the middle third of the scrotum, without clipping in the distal part.

The detachable skin flap has three sections:

- the first section is formed from the meatus by two parallel sections, its length is equal to the distance from the top of the head to the meatus, its width is twice the width of the first part (the urethral strip);

- the second section is equal to the length of the frenulum of the penis and tapers relative to the first section according to its width, while the width of the subcutaneous fascia remains the same as in the first section of the flap;

- the third section of the bridge-shaped flap has the shape of an isosceles trapezoid, and the width of the top of the flap in this section doubles in the lower section (the base of the flap).

The width of the subcutaneous fascia of the mobilized flap exceeds by 0.5 cm the width of the skin part; in the area of the base of the flap, on the scrotum, skin incisions end angularly, heading laterally at an angle of 80-90 °. The cut flap is lifted, bent in half at the border of the first and second parts (in the area of the future bridle). The excess part of the subcutaneous fascia of the moving part of the flap is laid and fixed with seams under the separated wings of the glans penis.

The method provides a good cosmetic and functional result of the operation, is a less traumatic, effective method of treating hypospadias, is easily reproducible in a hospital in the department of urology, pediatric surgery. The inventive method can be applied in pediatric and general urology, andrology in the surgical treatment of urethral abnormalities in children.

Thus, the claimed invention meets the criterion of "industrial applicability".

Explanations for figures 1-3.

Figure 1 - Scheme of skin incisions with plastic urethra by a longitudinal skin graft in the form of a "bridge": 1 - "urethral site", 2 - meatus, 3 - skin longitudinal ventral flap.

Figure 2 - Scheme of the departments of the skin flap in the form of a "bridge": 4 - "urethral section", 5 - the middle part (section of the inflection of the flap), 6 - the base of the flap;

Figure 3 - Mobilization of a longitudinal bridge-like flap of the skin: 7 - bed of the urethra, 2 - meatus, 8 - "skin bridge" for plastic urethra.

Please name the proposed method for the formation of a skin flap: "the method of urethral plastic bridge continuous flap of the velor surface according to Yu.A. Kravtsov-1."

Claims (1)

A method of forming a skin flap in urethral plastic surgery, including marking a skin flap, isolating a skin flap, creating neourethra by stitching a flap with an urethral bed, suturing a skin wound, characterized in that, in order to reduce the likelihood of postoperative complications from the wound (skin flap necrosis, formation insufficiency of the anastomosis and the formation of fistulas), increase the functional and cosmetic effects of the operation, a longitudinal continuous ribbon-like gloss is marked on the voluntary surface of the penis Having two parts, a first representing a narrow strip of skin to "urethral strip" of the head from the orifice, having parallel running edges; and the second part in the form of a bridge-like strip of skin, starting from the meatus and ending with the middle third of the scrotum, and the first part of the flap is not separated from the base, and the second part is separated from the cavernous bodies, the separated skin flap, in turn, has three sections, the first of which form from the meatus by two parallel sections, its length is equal to the distance from the top of the head to the meatus, the width is twice the width of the first part (the urethral strip), the second section is equal to the length of the frenum of the penis and narrows about relative to the first section, corresponding to its width, while the width of the subcutaneous fascia remains the same as in the first section of the flap, the third section of the bridge-shaped flap has a cone shape, the width of the top of the flap in this section doubles in the lower section (base), the bridge-shaped flap is all over along with the subcutaneous fascia, it is separated, its width exceeds by 0.5 cm the width of the skin part; in the region of the base of the bridge-like flap, on the scrotum, the skin incisions end angularly, directing them laterally at an angle of 80-90 °, the cut bridge-like flap is lifted, bent in half at the border of the first and second parts in the area of the future bridle, the bend is fixed with two skin sutures-holders, the suture line is closed by the bend of the bridge-like flap, after the formation of the neourethra with two rows of parallel sutures stitching the urethral strip and the first part of the flap, with the excess part of the subcutaneous fascia being laid and fixed ruyut sutures under otseparovannye wings head of the penis, when tightening the bridge and bend the flap on the side surfaces of the flap at the base of the scrotum is formed skin projections of triangular shape, which are cut off at the base, thus rectified line seams.

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