RU2722054C1 - Surgical treatment method of spongiform urethra strict strictures - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to urology. Ventral and dorsal urethral augmentation is performed with a graft from the oral mucosa. Before urethrotomy closure along ventral semicircle, ventral urethrotomatous dissection is prolonged on both sides by 2 cm with subsequent insertion of two rhombic buccal grafts with inversion of mucous membrane into urethral lumen. Thus, that their wide part is localized above end sections of distal and proximal augmentation, made on dorsal semicircle of urethra. Either the ventral and dorsal augmentation of the urethra is performed by a graft from the oral mucosa. If the proximal incision along the ventral semi-circumference changes into a bulb of the spongy urethra, two transverse matt sutures are applied in this zone at the level of the proximal incision on each side of the urethrosis. One rhomb shaped buccal graft with inversion of the mucous membrane into the urethral lumen is sutured into the distal incision, followed by suturing the entire urethrotoomic incision along the ventral surface of the spongiform body.

EFFECT: declared methods increase reliability of urethroplasty and allow reducing a risk of recurrences in zones of distal and proximal augmentation.

2 cl, 7 dwg, 2 ex

Description

The invention relates to medicine, namely to urology, and can be used in the surgical treatment of extended narrowing of the spongy urethra in men.

To date, the most successful method of surgical treatment of extended strictures of the spongy division of the urethra is augmentation (enlarging) urethroplasty.

Since 1993, surgeons involved in this type of reconstructive urology have begun to prefer augmentation material to transplants from the oral mucosa (El-Kasaby AW, Fath-Alla M., Noweir et al The use of buccal mucosa patch graft in the management of anterior urethral strictures // The Journal of urology, 1993, 149 (2), 276-278).

However, as experience gained and long-term results were evaluated, researchers began to note a rather high percentage of relapse of urethral narrowing after augmentation urethroplasty using buccal grafts.

The timing of the formation of clinically significant contractions, according to the literature, varies. Thus, the authors note that 21% of relapses occurred in the first 3 months after the operation, 40% were registered after 6 months and 55.4% - 12 months after the urethral augmentation. Relapses of urethra narrowing were most often found at the sites of anastomosis of grafts with a spongy body in the area of its dissection (LiuJ. S., Dong C, Gonzalez S.M. Risk factors and timing of early stricture recurrence after urethroplasty // Urology, (2016). 95, 202-207).

One of the reasons for the development of recurrent narrowing of the urethra after performed urethroplasty is the inadequate fulfillment of urethrotomy along the length, where augmentation of the narrowed section of the urethra is directly carried out, which is proved by comparative studies of MRI and X-ray data with an assessment of both the localization of the stricture itself and the length of spongiofibrosis ( Dombrovsky V.I., Kogan M.I., Banchik E.L., Mitusov V.V. The role of magnetic resonance imaging in the diagnosis of stricture disease of the urethra in men // Urology, 2015, No. 2, 24-30).

The prior art method for surgical treatment of anterior urethral strictures in men, proposed by N.S. Asopa in 2001, including sequential dissection of the tissues of the penis to the ventral semicircle of the spongy urethra in the area of stricture narrowing, followed by its longitudinal dissection into the length of the stricture. After this, a second longitudinal dissection of the spongy urethra is performed, but already along the dorsal semicircle from the mucous membrane of the urethra. Urethral augmentation using a graft is performed in the area of this second dissection from the urethral lumen.

After the augmentation stage is completed, the urethra is restored by suturing the urethrotomy in the ventral semicircle of the spongy body with interrupted sutures (N.S. Asopa, M. Garg, GG Singhal, L. Singh, J. Asopa, A. Nischal, Dorsal free graft urethroplasty for urethral stricture by ventral sagittal urethrotomy approach // Urology 58: 657-659, 2001. © 2001, Elsevier Science Inc.).

The disadvantage of this technical solution is the stage of longitudinal suturing of the spongy body along the ventral semicircle of the urethra over the “end” augmentation sites, which naturally leads to a narrowing of the lumen of the hollow organ, which is the urethra, increasing the likelihood of stricture recurrence both in the distal and proximal areas dissection.

From the existing level of technology, a method for surgical treatment of anterior urethral strictures in men is known, including sequential dissection of the own fascia and bulbocavernous muscles of the penis and urethral stricture along the surface with a longitudinal incision, closing the defect by fixing a patch from an autograft and stitching a postoperative wound, characterized in that after dissection of the genital two flaps form a member of its own fascia and bulbocavernous muscles, the urethral stricture is cut longitudinally along the ventral surface, after which horizontal sections of 3-4 mm are made at the proximal and distal ends of the longitudinal section, the patch is formed in the form of a rectangle, and the postoperative wound is stitched by the tension of one flap on another with an overlap of 8-10 mm, while the outer edge of the other opposite flap is hemmed to the inner surface of one of the flaps, with the creation of tension, over which the bottom flap and fix it to the outer surface of the hemmed flap (RF patent No. 2301024, publ. 06/20/2007).

Its main drawback should be considered that this method of treating urethral strictures can only be used at the middle third and in the proximal part of the bulbous urethra, since in its implementation an important role belongs to the bulbo-cavernous muscles, which are anatomically absent in the area of the penile and distal parts of the bulbous urethra.

A known method of treating extended anterior urethral strictures in men, including longitudinal dissection of its stenotic part with an extension of the incision into healthy tissues by at least 0.5 cm in each direction and replacing the resulting urethral defect with a patch formed from an autograft of the cheek mucosa, characterized in that in a patch formed from an autograft of the mucous membrane of the cheek and into the recipient bed, autoplasma enriched with platelets is introduced at the rate of 0.5 ml per 1.0 cm of the length of the recipient bed (RF patent No. 2669049, publ. 05.10.2018).

The disadvantages of this technical solution are: the lack of "control" and true prevention of the likelihood of recurrence of urethral narrowing in the end sections of the urethral augmentation, which is most common in clinical practice. It should also be considered doubtful that a few milliliters of plasma enriched with platelets, and which will be absent at the injection site in a few hours, can significantly affect the nature of the graft engraftment, the repair of which takes place over a single week, as proved by histological studies and in the experiment, and in the clinic.

A known urethroplasty method developed in 2002 by Professor Enzo Palminteri and described in the article: Combined Dorsalplus Ventral Double Buccal Mucosa Graftin Bulbar Urethral Reconstruction E. Palminteri, G. Manzoni, E. Berdondini, F. DiFiore, G. Testa, M. Poluzzi, A. Molon // EuropeanUrology, January 2008 (Vol. 53, Issue 1, P. 81-90).

The method consists in combined augmentation of the anterior urethra, including ventral augmentation of the urethra throughout the stricture with supplemented dorsal augmentation in the area of greatest narrowing of the urethra, using at least two flaps of the mucous membrane of the cheek as a plastic material.

The technical solution of the method lies in the fact that after the longitudinal opening of the urethral lumen throughout the stricture along the ventral surface, dissection of its dorsal surface from the mucosa (from the urethral lumen) to the cavernous bodies is performed. Two free grafts are formed from one mucous buccal flap. One of the grafts is transplanted into the dorsal defect of the urethral mucosa, and the other is sutured with the edges of the ventral incision of the urethral mucosa. Then, over the flap, the edges of the dissected spongy body of the urethra are sewn along its ventral semicircle.

The main drawback of this technique should be considered that with the use of extended ventral augmentation, the probability of success of the operation is sharply reduced, in contrast to the dorsal, due to the worse vascularization in paraurethral tissues, which are responsible for the direct engraftment of the graft. This is especially important in the penile section, where paraurethral tissues are represented by the fascia of the Buck, the vascularization of which is extremely scarce. The closure of ventral dissection by suturing the edges of the dissected spongy body also raises a question, since with this technique the very meaning of ventral augmentation is lost, because the graft is agglomerated and will “sink” into the urethral lumen.

The prototype of the proposed method, we have selected a method of urethroplasty, including performing ventral and dorsal augmentation of the anterior urethra with the formation of grafts, the main and additional, when performing dorsal augmentation, the graft is formed from the mucosa of the cheek, characterized in that the dorsal augmentation of the anterior urethra is carried out throughout its narrowing, separating the urethra from the cavernous bodies, and the ventral at the site of its maximum narrowing, increasing the incision of the urethra proximal and distal until the catheter is previously inserted into the lumen of the urethra, the dorsal graft is used as the main one, and the ventral graft is additional, and the additional graft is formed from the mucous membrane of the tongue ( RF patent No. 2391921, publ. 06/20/2010).

The method we have chosen as a prototype has the following disadvantages.

1. The author's method of urethroplasty involves extensive anatomical "skeletonization" of the urethra, in order to subsequently rotate it by 180 ° and perform augmentation on the dissected dorsal surface. This technique is known and valid. But in the future, on the "skeletonized" urethra, a second incision is performed, which is extremely undesirable. This is due to the fact that the spongy body against the background of pronounced spongiofibrosis is already ischemic earlier due to the intersection of all communicative and perforant vessels from the paraurethral and intercavernous or intercrural space. An additional incision will sharply increase ischemia in the remaining spongy body, thereby significantly increasing the likelihood of recurrent stricture formation.

2. An additional insertion of the graft along the ventral surface in the area of the preserved narrowing (where the catheter does not pass) indicates that the principal task of the dorsal augmentation - eliminating the narrowing is not solved, either the graft of the wrong width, or it is incorrectly fixed to the spongy body and tightly lack of mobility sewn to the intercavernous or intercrural space.

3. The technique of suturing a graft through the ventral semicircle does not prevent the formation of recurrent strictures in the most problematic areas of dorsal augmentation — the end sections of the suturing of the graft to dissection of the spongy body in the dorsal semicircle.

4. Surgeons who are engaged in augmentation urethroplasty with long urethral strictures where the oral mucosa is used, try to minimize cases where for this purpose the graft is harvested from the mucous membrane of the hyoid region, due to its thinning compared to the areas of the cheek and lips, complex technique of execution, high risk of complications after surgery and massive bleeding during its implementation.

These shortcomings are eliminated in the claimed technical solution.

The objective of the invention is to increase the reliability of urethroplasty with extended strictures of the spongy urethra.

This problem is solved due to the fact that they perform ventral and dorsal augmentation of the urethra with the formation of grafts, and, before suturing the urethrotomy along the ventral semicircle in the operated section of the spongy urethra, the urethrotomy is elongated along the ventral semicircle of the spongy body from both sides on 1.5 -2 cm and they are sewn into them two diamond-shaped buccal grafts 3-4 cm long, with inversion of the mucous membrane into the urethral lumen, so that the widest part is localized above the terminal sections of the distal and proximal augmentation, performed earlier on the dorsal semicircle of the urethra; if the proximal dissection along the ventral semicircle is in the proximal part of the bulbous urethra in the bulb area, then in this zone two or three transverse mattress sutures are placed at the level of proximal dissection and one rhomboid buccal graft is sutured into the distal dissection zone, followed by suturing of the entire urethral dissection along the spongy body.

The technical result provided by the given set of features is:

- restoration of patency of the urethra with extended strictures in any part of the spongy urethra;

- restoration of natural urination and ridding the patient of urine derivation through a cystostomy, which means improving the patient's quality of life;

- minimization of the risk of relapse in the distal and proskimal augmentation zones due to additional rhomboid buccal graft, providing an increase in the internal urethral lumen in these zones.

The proposed technique of augmentation urethroplasty allows minimizing the likelihood of a relapse of urethral narrowing in the distal and proximal augmentation zones due to the fact that additional inserts of rhomboid buccal grafts on the opposite side prevent narrowing of the lumen of the spongy urethra when it is sutured transversely except for the zone of the urethral bulb, where its width and mobility allows you to restore its integrity using the technique of suturing a cavity rounded organ according to Heineke-Mikchulich with interrupted (mattress) sutures.

The restoration of urethral patency with extended strictures in any part of the spongy urethra occurs due to a decrease in the likelihood of recurrent narrowing of the urethra, especially in the distal and proximal parts of the urethral augmentation, performed in the dorsal semicircle due to the insertion of rhomboid buccal grafts in these zones, but the semicircle where the urethrotomy is performed.

The invention is illustrated by drawings (1-7), which show the features of the method.

FIG. 1. Intraluminal augmentation fixation of the graft along the dorsal semicircle of the urethra;

FIG. 2. Elongation of the urethrotomy dissection along the ventral semicircle of the spongy body on both sides (indicated by a dotted line);

FIG. 3. Fixation of rhomboid buccal grafts in the terminal sections of the urethrotomy in the ventral semicircle of the spongy body (one graft is shown fully fixed, the second partially);

FIG. 4. Urethrotomy dissection between the transplant inserts sutured;

FIG. 5. The application of mattress sutures along the additional proximal dissection at the level of the bulb of the bulbar urethra;

FIG. 6. Fixation of a rhomboid buccal graft in the area of additional distal urethrotomy dissection. The mattress sutures at the bulb level are tied;

FIG. 7. The final view after urethroplasty, when the proximal segment of the stricture is located in the bulbous urethra in the area of its bulb.

A detailed description of the method and examples of its clinical implementation

Preoperative examination included the collection of patient complaints, an anamnesis of the course and development of the disease, examination of the patient with an assessment of his urination at the time of hospitalization - saved urination in a natural way or urine derivation through cystotomy drainage. The most important diagnostic technique that determined the subsequent surgical treatment was an X-ray examination of the urethra in the form of retrograde and mycotic cystourethrography.

All operations were performed in the usual lithotomy position or the position of the patient on the back, which was determined by the localization zone of the stricture. For strictures localized in the penile region, this is the position on the back, while localization of strictures in the bulbous section, this is the lithotomy position.

The procurement of transplants from the mucosa of the cheek or lower lip was carried out according to the standard technique (Oral mucosa harvest: an overview of anatomic and biologic considerations / MR. Markiewicz [et al.] // EAU-EBU Update Series. - 2007. - Vol. 5. - P. 179-187).

After performing standard augmentation urethroplasty in the longitudinal section section along the dorsal semicircle of the urethra according to the Asopa technique (Fig. 1), urethrotomy dissection along the ventral semicircle of the urethra was extended by 1.5-2.0 cm in both directions (Fig. 2).

Two rhomboid grafts 3-4 cm long were sewn into the additional dissection zones, with the mucous membrane inverted into the urethral lumen, so that their widest part of the rhomboid buccal graft was localized over the terminal sections of the distal and proximal augmentation, performed earlier on the dorsal semicircle of the urethra (Fig. 3).

The urethrotomy zone between the rhomboid transplant inserts along the ventral semicircle is sutured as standard (Fig. 4).

If the proximal part of the stricture and subsequent augmentation of the urethra is performed in the bulbous area of the bulbous urethra, additional proximal urethrotomy is performed in the same place, from it 2 to 3 mattress sutures are placed along both sides, which is determined individually and depends on the thickness of the spongy body of the urethra . These sutures are tied, thereby creating an enlarged urethral lumen in this zone - the proximal augmentation zone (Fig. 5).

A rhomboid buccal graft is sewn into the zone of additional distal dissection (Fig. 6), followed by suturing of the entire urethrotomy dissection along the ventral surface of the spongy body (Fig. 7).

The performance of the proposed method is confirmed by the following clinical examples:

Example 1

Patient G-s, 47 years old, was hospitalized at the Urology Clinic of Rostov State Medical University with a diagnosis of: Extended stricture of the bulbous urethral section, cystostomy for surgical treatment.

-обследовании выявлена стриктура уретры, по поводу которой выполнялись неоднократные бужирования и внутренние оптические уретротомии. Эффект от лечения был кратковременный. В 2014 году выполнена открытая операция на уретре - резекция стриктуры по технике Хольцова. После операции мочился самостоятельно, но с выраженными дизурическими расстройствами, которые усиливались год от года и в ноябре 2017 года трансформировались в острую задержку мочи, которая была разрешена установкой троакарного цистотомического дренажа.From the anamnesis: regarding acute gonorrhea urethritis in 2000, urethral instillations were performed with a silver solution, which led to a burn of the urethra. A few months later, the symptoms of the lower urinary tract began to increase. At

- examination revealed a stricture of the urethra, for which repeated bougienage and internal optical urethrotomy were performed. The effect of the treatment was short-lived. In 2014, an open operation on the urethra was performed - a stricture resection according to the Holtsov technique. After the operation, he urinated on his own, but with severe dysuric disorders, which intensified from year to year and in November 2017 transformed into acute urinary retention, which was allowed by the installation of a trocar cystotomy drainage.

During the preoperative examination in the clinic, the presence of an extended (6-7 cm) stricture in the urethral bulbous section was established.

The operation is performed according to the claimed method in the lithotomy position of the patient.

After opening the lumen of the urethra and verification of stricture narrowing, the length of which was 6 cm, standard augmentation urethroplasty using the Asopa technique was performed on the ventral semicircle from the side of the urethra.

After its completion, elongation of the urethrotomic dissection along the ventral semicircle in both directions with a length of 2 cm was performed.

Considering that the proximal augmentation site is located in the proximal part of the bulbous urethra, and the additional section in this area is in the bulb area, the additional proximal section is sutured with four mattress sutures (two on each side) using the Heineke-Mikchulich technique.

One harvested rhomboid buccal graft with a diagonal length of 4 cm and its inversion along the plane is sewn into the zone of additional ventral dissection so that the mucous membrane is in the urethral lumen.

Then, standard suturing of the urethrotomy site along the ventral semicircle between the rhomboid graft and the transversely sutured bulb was performed. Layer wound closure.

The course of the postoperative period without complications with the healing of the postoperative wound by primary intention.

On the 21st day after the operation, the patient underwent control pericatheter urethrocystography, which revealed the absence of sagging contrast medium into the paraurethral space, which served as the basis for the removal of the urethral catheter. Restored self-urination in a natural way, with a good stream. The patient was discharged from the ward in satisfactory condition. Clinical status at discharge - recovery.

Example 2

Patient Iev, 64 years old, was treated in the urology clinic of Rostov State Medical University with a diagnosis of multifocal urethral stricture, cystostomy.

Anamnesis of the disease: In 2005, a dull trauma to the perineum, with an increase in dysuria up to an OZM, which required the installation of a cystostomy and subsequent surgical treatment in the amount of urethral resection. This complex of therapeutic measures allowed to save the patient from cystostomy. However, the patient failed to restore full-fledged quality urination in the patient. Periodically, therapeutic bougienages were performed, in 2013 and 2017 - internal optical urethrotomy. In May 2017, in connection with the newly emerged OZM, a cystostomy was established and the patient was recommended to continue treatment in the urology clinic of Rostov State Medical University.

At the time of hospitalization in the clinic - derivation of urine from the patient through cystotomy drainage. According to the ascending and mycotic urethrocystograms, a multifocal lesion of the urethra was revealed - a stricture up to 1.5 cm long in the bulbous-membranous section and an extended (5-6 cm) stricture in the glandular and penile sections of the urethra.

Given the survey data, the clinical course of the disease, the surgical treatment of the disease, it was decided to divide into two stages:

Stage 1 of surgical treatment - the elimination of urethral obstruction in the area of the bulbous-membranous urethra, the creation of a neomeatus in the area of proximal narrowing in the penile region and the patient’s cystostomy;

The 2nd stage of surgical treatment is urethroplasty according to the claimed method in the penile sections of the urethra using grafts from the oral mucosa.

04/26/2018, the patient underwent a resection of stricture of the proximal part of the bulbous urethra with an end-to-end anastomosis and marsupialization of the penile part of the urethra with the formation of neomeatuses on the ventral surface of the penis proximal to the coronal groove by 3 cm and closer to the penoscrotal angle.

The postoperative period was uneventful with wound healing by primary intention. On the 10th day, the suprapubic urinary fistula was healed, and on the 14th day the urethral catheter was removed and independent urination was restored through the formed neomeatus in the penoscrotal angle.

Re-hospitalized in the clinic after 10 months to perform 2 stages of surgical treatment.

At the time of hospitalization, urination is independent, free through the neomeatus on the ventral surface of the penis in the penoscrotal angle.

03/15/2019, the patient underwent urethroplasty of the penile urethra according to the claimed method using transplants of the mucous membrane of the oral cavity with a length of 5-6 cm. Surgery was performed with the patient on his back.

Initially, a graft was sewn all over the marsupialized urethra zone, and then the edges of the marsupialized urethra were stitched together using two rhomboid buccal grafts 2.0-2.5 cm long along the ventral semicircle in the proximal and distal sections of the urethra restored after marsupialization.

The postoperative period was uneventful. The urethral catheter was removed on the 21st day after the operation and natural urination was restored. Clinical status at discharge - recovery.

The claimed method treated 11 patients with extended strictures of the spongy urethra. The results of observation for 6 months showed the absence of relapses and postoperative complications, which confirmed the effectiveness of the proposed method in the treatment of extended spongy urethral strictures in men.

The claimed method of treatment of extended strictures of the spongy urethra is effective to improve the quality of life of patients by restoring natural urination and ridding the patient of urine derivation by means of a cystostomy.

It allows to reduce the risk of relapse in areas of distal and proskimal augmentation due to additional rhomboid buccal grafts, which increase the internal lumen of the urethra in these areas, increases the reliability of urethroplasty compared to the known ones.

The inventive method has been tested in clinical practice and can be recommended for widespread use in urological hospitals.

Claims (2)

1. A method of surgical treatment of extended spongy urethral strictures, including performing ventral and dorsal augmentation of the urethra with a transplant from the oral mucosa, characterized in that before suturing the urethrotomy along the ventral semicircle, 2 cm elongation of the ventral urethrotomy is performed on both sides, followed by suturing rhomboid buccal grafts with inversion of the mucous membrane into the urethral lumen, so that their wide part is localized over the terminal sections of the distal and proximal augmentation performed by the dorsal semicircle of the urethra. 2. A method for the surgical treatment of extended spongy urethral strictures, including performing ventral and dorsal augmentation of the urethra with a transplant from the oral mucosa, characterized in that when the proximal dissection along the ventral semicircle passes to the bulb of the spongy urethra, in this zone at the level of proximal dissection two transverse mattress sutures on each side of the urethrotomic dissection, and one rhomboid buccal graft with inversion of the mucous membrane into the urethral lumen with subsequent suturing of the entire urethrotomy dissection along the ventral surface of the spongy body is sewn into the distal dissection zone.

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