RU2460473C2 - Method of surgical treatment of peyronie's disease - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, in particular to andrology. Method includes skeletonisation of penis, exposure of section of fibrosis of tunica albuginea, its excision within healthy tissue and covering defect with transplant by method of rotation of foreskin skin flap. Before operation 0.5% solution of methylene blue with novocaineis introduced under layers of foreskin in half-dilution in volume 0.5 ml in both lateral zones of penis. After that two flaps of foreskin on vascular pedicle are cut out, their deepithelisation and counter-rotation towards defect are performed. Layers are passed under vascular-nervous bundle, sutured to each other, transferred layers are fixed to cavernous bodies, sutures are applied in staggered order.

EFFECT: method makes it possible to cover large defects of tunica albuginea and prevents post-operation complications.

1 ex, 3 dwg

Description

The invention relates to medicine, namely to surgical methods for treating Peyronie's disease, in particular, using transplantation of the penile membrane, and can be widely used in andrology.

Peyronie's disease or fibroplastic induction of the penis is a disease that is manifested by the presence of single or multiple seals in the connective tissue of the protein coat, the so-called plaques. According to various authors, it has a small prevalence: from 0.3 to 2% (M.V. Lindsay et al., 1991; G.H. Jordan, S.M. Schlossberg, C.J.Devine, 1998). Fibroplastic changes lead to angular deformation and pain syndrome when an erection occurs, which does not allow sexual intercourse, or it is extremely difficult to carry out it.

Peyronie's disease is more common in men between the ages of 20-60. The symptom complex includes: the presence of plaque, curvature of the penis, painful erection, some of the symptoms may be prevailing. In Peyronie's disease, there is a local disorganization of the circular and longitudinal layers of the protein coat, as well as ruptures of elastin, a decrease in its content with a simultaneous increase in collagen, which leads to the curvature of the penis at the time of an erection.

The developed and applied methods of treating Peyronie's disease are divided into two groups: conservative and operational.

Conservative:

• Injection of steroid drugs into the plaque.

• Extracorporeal shock wave therapy.

• Physiotherapeutic methods.

Operational:

• Corporoplasty.

• Correcting corporoplasty due to transplant.

• Phloendoprosthetics.

Conservative therapy for Peyronie's disease is highly variable, which is associated with a low degree of its effectiveness. Conservative methods (the introduction of hormones into the plaque, etc.) lead only to a slight temporary effect, exacerbate the pathological process.

Of the injectable preparations injected into the plaque, verapamil, interferon and orgotein were also proposed. However, the use of drugs directly injected into the plaque leads to significant positive results, but their use is associated with toxic effects on the body and individual intolerance. The drug Orgotein is quite effective, but its use is associated with high toxicity, and in some countries its use is prohibited (G. Bartsch, K. Menander-Huder, 1981).

Recently, in urological clinics, they have increasingly begun to use traditional stone crushing devices for plaque destruction. The initial results of extracorporeal shock wave therapy are regarded by the researchers as encouraging (Y. Abdel-Salam et al., 1999; T. Lebret et al., 2000; EWHaucks et al., 2000; J. Husain et al., 2000; MS Mishel et al., 2003; O.I. Pakus, 2005). Nevertheless, the use of shock wave therapy is not widespread (V. Mirone, C. Imbimdo et al., “A new biopsy technigue to inverstigate Perronies disease associated histological alterations: results in two different forms of terapy”, Eur.Urol. 2002) . There is evidence of complex therapy for the use of verapamil and antioxidants in combination with lithotripsy (Alyaev Yu.G., Rapoport L.M., Scheplev P.A. Combination therapy of penile fibroplastic induction. Andrology and genital chir., 2003).

Currently, the use of drug therapy is recognized only in the acute inflammatory phase. In the chronic phase, in the stabilization phase of the process, combination therapy or surgical treatment methods are more effective.

The technique of plication of the protein coat on the contralateral side leads to a shortening of the penis.

Surgical treatment of Peyronie's disease is still the most reliable and fastest way to eliminate penile curvature. Nevertheless, the problem and issues of surgical treatment of this disease continue to be extremely urgent and compel us to search for the development and use of the most effective surgical techniques for performing the operation, which is primarily due to the versatility of the clinical manifestations of the disease. Currently, the nature of the operations that are used for the surgical treatment of Peyronie's disease is divided into three groups: a) corporoplasty; b) rectifying corporoplasty due to transplant; c) phalloendoprosthetics.

The most common surgical methods for treating Peyronie's disease are corporoplasty according to Nesbit (1965) and Schroeder-Essed (1985). The technique of the operation consisted in excising ellipses with a diameter of 1.5-3.0 mm Tunica albuqinea on the opposite side of the bend of the penis, at the rate of 10 ° curvature - one ellipse of tissue excision. When the edges of the surgical wound were closed, the more elongated side of the membrane was shortened, thereby curving the penis at the time of erection leveled (Journal of Urology, 1965, Volume 93, page 230-232).

The advantage of these methods is a relatively short rehabilitation period, but they also have a serious drawback - the penis corrected in this way becomes shorter, and the shortening of the penis is 1.0 cm based on 30 ° of curvature, which should be estimated and agreed upon in advance with the patient.

In patients who cannot agree with the inevitable shortening of the penis using the above methods, it is most advisable to use a replacement transplant instead of an excised plaque. In addition to free skin and fiber vein patches, muscle aponeurosis, fascial tissues, prepared cadaveric (pericardium, dura mater and serous intestinal) tissues are used as transplants. In recent years, artificial tissue substitutes have become widely used as transplants.

It should be noted that our own studies on the use of various tissues as a transplant: a de-epithelized dermoid flap, a synthetic pericardium and a large saphenous vein, revealed the best results when using a venous graft. However, not all patients can take a saphenous vein, or its volume may not be enough. Synthetic pericardium or lyophilized dura mater belong to foreign implants, which does not exclude various reactions of the recipient's body, in addition, they differ in structure from the albumen.

A known method of surgical correction of the organic form of erectile dysfunction due to Peyronie’s disease (RF patent No. 2179827, 2002.02.27). The method consists in dissecting the fibrous plaque of the protein membrane, performing intracavernous prosthesis of the penis with prostheses and then closing the defect formed in the protein membrane of the penis with a flap of plasticized material, according to the invention, the intracavernous prosthesis is performed incompletely, introducing the prostheses from the capitate to the basal body and bending fix them twice with non-absorbable material, and use rigid prostheses, the diameter of which is less than the maximum diameter to vernoznogo body, and as the graft material employed lyophilized dura. The method is performed by patients with Peyronie's disease in the stabilization stage with a curvature of the penis of more than 30 degrees in the presence of organic erectile dysfunction (insufficiency) II or III degree.

The disadvantage of these methods of treatment is that with severe curvature of the penis (more than 30 degrees in an erection state), which happens with a large size of the fibrous plaque of the protein membrane, causing a narrowing of the lumen of the cavernous body, it is technically impossible to establish an intracavernous prosthesis and correct the curvature.

Also described is a method of surgical correction of erectile deformity in Peyronie’s disease (RF patent No. 2234257, 2004.08.20), including penile skeleton, isolation of the fibrosis of the albuminous membrane, excision of it within healthy tissue and closure of the defect with a graft, using vascularized as a graft plot of the upper third of the saphenous vein, which is carried out under the skin of the penis of the intima inward.

The main disadvantages of such operations include:

- insufficiently complete correction of the curvature due to the impossibility of a clear and uniform closure of the defect, because the main stage of the operation, after excision of the plaque, is performed outside the state of artificial erection;

- this type of surgical intervention in 12-15% of cases is associated with increased erectile dysfunction of a vascular nature due to an increase in veno-occlusive protein membrane insufficiency.

- a high risk of complications in the form of postoperative erection dysfunction and the fact that when a vein fragment is removed, another skin defect inevitably occurs.

A known method of treating Peyronie’s disease and erectile dysfunction (RF patent No. 23033405, 07.27.2007), including a skin incision along the coronary sulcus, mobilization of integumentary tissues to the base of the penis and excision of fibrous plaque, characterized in that longitudinal corporotomy is performed along the lateral surface of the penis fibrous plaque is excised from the inside of the cavernous bodies, cavernous bodies are proximal and distal with the formation of itracavernous channels, plastic falloprostheses are implanted in them and the corporotomy is sutured seam.

A known method for the surgical treatment of Peyronie’s disease and erectile dysfunction (RF patent No. 2376942, 12/27/2009), including an incision along the coronary sulcus, mobilization of integumentary tissues to the base of the penis, excision of fibrous plaque within healthy tissues, pacing of cavernous bodies through a defect in the tunica alba and implantation of plastic prostheses, comparable in length to the length of the cavernous canals, closure of the defect of the protein membrane and the application of skin sutures, characterized in that through the midline incision along the anterior abdominal wall fill the right portion of the rectus abdominis muscle with a fragment of its vagina on the supply vessels, move the muscle fragment under the skin of the penis, close the defect in the protein sheath with a fragment of the rectus abdominis muscle so that the fascia fragment is fixed to the edges of the protein defect, and the muscle is fixed to lateral surfaces penis on one side and the other, the integumentary tissue of the penis is returned to its place, skin sutures are applied and the wound of the anterior abdominal wall is sutured.

A known method of surgical treatment of Peyronie’s disease (RF patent No. 2376943, 12/27/2009), including an incision along the coronary groove of the penis, mobilization of integumentary tissues to its base, excision of fibrous plaque within healthy tissues, muscle transplant sampling, followed by closure of the defect of the protein coat and suturing the wound of the penis, characterized in that after an incision along the coronary sulcus of the penis and mobilization of integumentary tissues, a dorsal neurovascular bundle of the penis is mobilized to its base, Through a midline section along the anterior abdominal wall, a right portion of the rectus abdominis muscle is taken with a fragment of its vagina on the supply vessels, a muscle fragment is moved under the skin of the penis, plastic membrane defect is plasticized with a fragment of the rectus abdominis muscle so that the fascia fragment is fixed to the edges of the protein defect shell, and muscle - to the lateral surfaces of the penis on one and the other side.

Scheplev P.A. proposed to replace the protein membrane with a fragment of the broadest fascia of the thigh (Scheplev PA / Reconstructive and aesthetic surgery of the penis: Diss. and author. thesis. ... other medical sciences. M: 1996). Professor Sokolchik M.M. in 2009, he suggested replacing a defect in the protein membrane with a combined displaced muscular-fascial flap on the feeding vascular pedicle.

The disadvantage of the proposed methods for closing defects in the protein coat is the need for additional incisions during the sampling of the fascia of the thigh, section of the vein, skin or muscle-fascial flap. The use of synthetic materials or cadaveric prepared material (meninges, etc.) can cause an allergic reaction, a rejection reaction. Also, the disadvantage of these techniques is that there is a need for several incisions, which increases the degree of surgical injury, creates a threat of microcirculation disturbance in the area of the displaced flap, taking into account the need for rotation, the degree of postoperative risk of the graft. It is also necessary to consider the complexity of the methodology, the need for additional education and training of a specialist.

Closest to the proposed method, which we adopted as a prototype, in our opinion, is the method of plasticizing the white membrane by a vascularized flap of the foreskin by rotating the skin flap of the foreskin (S. Krishnamurti // Penile dermal flap for defect reconstruction in Peyronies disease. - Int. J .Inpotens Res. 1995. - 7. - P.195-208).

This method has the disadvantages of the above methods.

The task of the invention is to increase the effectiveness of the treatment of patients with Peyronie's disease and defects in the protein coat, reducing the degree of operational risk and simplifying the surgical approach.

To achieve this, we use rotated counter skin flaps of the foreskin on the vascular pedicle. The flap is cut and separated from the anterolateral and posterolateral arteries of the penis, taking into account the blood supply to the leaves of the foreskin, departing from the superficial arteries of the penis - from the external genital artery and venous outflow through the veins of the same name, and blood supply is also carried out from the vessels of the meaty membrane of the penis. The donor leaf is stitched through all layers to the cavernous bodies, the stitches are stitched. Previously, before the operation, a 0.5% solution of methylene blue with a solution of novocaine is introduced, in half dilution between the sheets of the foreskin in a volume of 0.5 ml in both lateral zones of the penis.

The technical result achieved by using the invention is as follows.

Using rotated counter flaps of the foreskin on the vascular pedicle, we achieve:

1) the absence of additional cuts, because when separating and skeletonizing the penis when approaching the plaque and defect of the protein coat, the final stage of the operation is the excision of the excess skin of the foreskin;

2) minimization of cicatricial degeneration and deformation in the plastic zone due to the fact that the sheets of the foreskin are formed on the vascular pedicle;

3) the exclusion of allergic reactions and rejection reactions, due to the fact that the tissues used are their own;

4) high transplant survival due to the fact that the flaps are cut taking into account the anatomical blood supply of the foreskin and the methods of vascular imaging were applied;

5) to prevent the displacement of the flap, its deformation and improve its viability due to the fact that the donor sheet is fixed to the cavernous bodies in a checkerboard pattern.

We achieve a decrease in the degree of damage to the donor leaf and the vessels supplying the donor leaf due to the fact that we additionally applied the technique of contrasting the vessels using 0.5% solution of methylene blue with novocaine in half dilution.

Thus, the claimed method of treating Peyronie’s disease provides the main advantage over the known ones: the ability to close large defects of the protein sheath of the penis, which allows the use of this technique for extending penile plastics on endoprostheses, and the reduction of postoperative complications.

The method is easy to use and does not require special training.

It should be noted that although the technique of contrasting blood vessels with a solution of methylene blue is widely used in the endolymphatic route of administration of drugs (Efimenko N.A., Chernekhovskaya N.E., Vyrenkov Yu.E. Guidelines for clinical lymphology. - M .: Russian medical Academy of Postgraduate Education, 2001. - 160 p.), however, in available sources of information there is no data on the use of this technique for plastic of the white coat of the penis.

The invention is illustrated in figures 1-3, which depict the stages of the operation.

Figure 1 - the place of cutting the flap from the foreskin of the penis.

Figure 2 - rotation and laying of the flap in place of a defect in the protein coat.

Figure 3 - suturing and fixation of the flaps in the protein coat of the penis.

A detailed description of the method and an example of its clinical use.

Examination of patients with Peyronie's disease upon admission and subsequent dynamic control during their treatment is carried out according to the following scheme: conversation, examination, general clinical laboratory examination methods; ultrasound methods, dopplerography and densitometry of the penis; computed magnetic resonance imaging of the penis; as well as special tests to evaluate erectile function.

Cutting the donor leaf from the foreskin skin is carried out, departing from the coronal groove by 0.5 cm. Given that the average circumference of the penis is approximately 12 cm, we can simulate a flap during rotation by 90% of 2 equal flaps of about 6 see. This will be its estimated length, and we model the flap width, departing from the initial section distally by the required amount. The incision between the donor leaves is carried out along the dorsal surface of the penis along the midline on the opposite side. Isolation is carried out as gently as possible on the superficial fascia of the penis in the region of its dorsal surface. We achieve sparing separation by visualizing blood vessels, for which, before surgery, 0.5% solution of methylene blue with novocaine in half dilution in a volume of 0.5 ml from the lateral sides of the penis is injected into the sheets of the foreskin. This allows you to contrast the lymphatic vessels and veins of the foreskin. Isolation and separation of tissues during closure of the defect of the tunica albuginea is carried out by the method of counter rotation of two flaps above the closable defect of the albumen of the penis obtained by excision of cicatricial induction. The leaves were held under the neurovascular bundle and stitched together, suture material prolene 5.0. The resulting large flap is fixed. Having previously assessed the size of the defect on the protein coat, the edges of the flap are excised and, turning the de-epithelized part to the cavernous bodies, they are fixed. First, the flap is fixed at the edges, the degree of deformation is checked by removing compression from the penis (tourniquet at the base of the penis). Then, with a continuous fillet suture, the protein membrane is sewn to its patch, the compression is again removed from the base of the penis and the presence of angular deformation is determined. The donor leaf is stitched through all layers to the corpora cavernosa with single interrupted sutures 1.0 cm apart, the sutures are staggered, which prevents the flap from shifting, deforming and improving its viability. Also, in the process of our observations, it was found that the larger the flap taken, the more it is necessary to leave a reserve for its reduction and possible degeneration, i.e. "Patch" should be more than a defect. They make final hemostasis and restore the integrity of the membranes of the penis, restore the integrity of the fascia of the tub with separate interrupted sutures, bypassing the vascular legs of the graft as distally as possible (leaving “windows” for the legs). The distal skin leaf of the penis is sutured with the proximal separate interrupted sutures (closure of a skin defect with circumcision). Active aspiration drainage is established for one day, iodoperon, aseptic dressing.

In the postoperative period, no complications were observed, and hematomas were not observed in the area of application of a mixed, rotated skin flap. The patient was usually discharged 3-4 days after surgery in satisfactory condition. Observation within 12 months after the operation notes the absence of progression of deformity, which complicates intercourse.

Clinical example 1.

Patient: G-s, 54 years old, and / b No. 186847 from 01/30/2008. D-s: Peyronie's disease. Operation: plastic of the white membrane by rotated, oncoming rags of the foreskin on the vascular pedicle.

Before surgery, 0.5% solution of methylene blue with novocaine in half dilution in a volume of about 0.5 ml from the lateral sides of the penis is injected into the sheets of the foreskin.

Under anesthesia, departing from the coronal groove of 0.5 cm, a circular incision was made. Considering the stained vessels, 2 flaps of the foreskin were cut out on the vascular pedicle, their de-epithelialization and rotation in the direction of the defect. The leaves of the foreskin are dissected in a circular section in the area of the palpable plaque in its middle part. The skin leaf was separated in the proximal direction in a blunt and acute way, with parallel hemostasis. In the place of maximum curvature on the protein coat, in its middle third, a deep fascia was opened with a blunt and sharp path. Beech fascia along the lateral surfaces of the penis and together with the neurovascular bundle is separated from the protein membrane, taken on a holder and laid aside. In the area of the dorsal surface of the penis, symmetrical plaques with a length of more than 4.0 cm are determined, which are taken on “holders” and excised to normal tissues of the white membrane. Cut out donor sheets of the foreskin are rotated with a minimum turn of up to 90% and de-epithelized side to the side of the defect.

The leaves were held under the neurovascular bundle and stitched together, suture material prolene 5.0. The implant is sewn with a twist - fillet stitch, suture 5.0. The integrity of the protein coat is restored. The donor leaflet is stitched through all layers to the cavernous bodies, stitches in a checkerboard pattern, single knotted stitches in vikril 5.0. Tumor caused by a physiological solution of 20.0 ml, administered intracavernosally. Controlled the elimination of angular deformation. Hemostasis. The postoperative wound was sutured in layers, the integrity of the deep fascia was restored (suture material vikril - 4.0). The proximal skin sheet is returned to its original place, the sheets of the foreskin are sewn with separate interrupted sutures (suturing of the skin defect with circumcision). Active drainage installed. Iodine, aseptic pressure dressing.

No postoperative complications were observed. No hematomas were observed in the area of implant placement. The patient was discharged on the 4th day in a satisfactory condition. Observation for 1.5 years showed the absence of angular deformation of the penis.

We have 2 years of experience observing a group of patients (4 men) who underwent plastic penis with rotated, oncoming rags of the foreskin on the vascular pedicle. Two noted slight angular deformation (less than 10 degrees), which allowed them to have normal sexual intercourse. The pain syndrome is stopped at all. Erectile dysfunction in all patients was not observed during the observation period.

Statistical processing of the obtained data was carried out using the application package Statistica 6.0 Excel 2002 spreadsheets.

Advantages of the method:

- Lack of additional cuts, as when the penis is isolated and skeletonized when approaching the plaque and the defect of the protein coat, the final stage of the operation is the excision of the excess skin of the foreskin.

- Minimization of cicatricial degenerations and deformations in the plastic zone, because leaflets of the foreskin are on the vascular pedicle.

- The absence of an allergic reaction and rejection, as own fabrics are applied.

- Increased transplant survival.

- The ability to close large defects of the protein coat of the penis, which allows you to apply the technique and with lengthening plastics of the penis on endoprostheses.

- Reducing the number of relapses and deformities in the surgical treatment of Peyronie's disease, because the method of counter rotation of two flaps is applied.

- This method of surgical treatment of Peyronie's disease is more productive and economical, in comparison with plastics performed by lyophilized dura mater or synthetic pericardium, thigh fascia.

The inventive method of surgical treatment of Peyronie's disease has been tested on sufficient clinical material, has shown its effectiveness and can be recommended for use in specialized surgical hospitals.

Claims (1)

A method for the surgical treatment of Peyronie’s disease, including skeletonization of the penis, isolation of the fibrosis of the albuminous membrane, excision of it within healthy tissue and closure of the defect by transplant using the method of rotation of the skin flap of the foreskin, characterized in that before surgery, 0.5% of the foreskin is preliminarily inserted a solution of methylene blue with novocaine in half dilution in a volume of 0.5 ml in both lateral areas of the penis, then two flaps of the foreskin are cut out on the vascular pedicle, producing DYT deepitelizatsii and their counter-rotation in the direction of the defect, the sheets carried by the neurovascular bundle, sewn between them, substituting the resulting defect tunica albuginea displaced sheets fixed to the cavernous bodies, the stitches applied in a staggered manner.

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