RU2723744C1 - Method for surgical treatment of bulbous urethra extended strictures in men - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, specifically to urology. After longitudinal incision along the ventral surface of the bulbous portion of the urethra, a buccal mucosa graft with the surface inwards is stitched on the Foley catheter No. 20 Ch, edge of urethra is sutured with graft edges using monocryl 4/0 with 17 mm long needle, continuous suture. That is followed by replacement of the urethral catheter with a metal bougie No. 20 Ch, edges of a dissected spongiform body above the graft are compared and closed with separate interrupted sutures monocryl 4/0 with needle 17 mm long with a buccal graft grip with a pitch frequency of 5 mm and also on both sides parallel to seam line, stitching of tissues of spongiform body is performed with buccal graft catching with pitch frequency of 5 mm, longitudinally relative to incision line of spongy body, then, the bougie is replaced with Foley catheter No. 16.EFFECT: method enables increasing the possibility of correcting more extended strictures, reducing the number of postoperative complications and recurrences, improving blood supply in the graft adjoining area to the spongiosum tissue.1 cl, 2 dwg, 1 ex

Description

The invention relates to medicine, in particular to urology, and may find application in the surgical treatment of extended strictures of the urethral bulbous region.

Urethral strictures in men are found in 0.6% of patients over 55 years of age (Brandes S., 2008). Narrowing the lumen of the urethra leads to obstructive uropathy and the appearance of symptoms that reduce the quality of life of urinary disorders. Urethral stricture usually occurs due to blunt perineal injury, instrumental and surgical procedures on the urethra, or gonorrhea urethritis.

Adverse effects of surgical intervention in this area are possible due to the anatomy: impaired ejaculatory function, namely a weakened ejaculate ejection due to damage to the periurethral muscles (bulbocavernous); post-injection digestion of urine due to weakness of the periurethral muscles; shortening of the penis and / or reduction of the erection angle due to resection of more than 2.0-2.5 cm of the bulbous urethra (https://medbe.ru/materials/striktury-uretry/anatomiya-muzhskogo-mocheispuskatelnogo-kanala-primenitelno-k -probleme-ego-suzheniy /).

Despite the improvement of surgical technique, the treatment of patients with extended strictures of the urethral bulbous region is a difficult and not completely solved problem of modern urology. Most experts believe that when the scar process spreads to the spongy body of the penis, the probability of cure is small, and either excision of the scar tissue with the formation of anastomosis or replacement urethroplasty is required.

Obviously, the possibility of performing anastomotic urethroplasty without tension is limited by the length of the resected area, so the use of patchwork reconstruction is indicated for extended strictures. The use of free flaps of the mucous membrane for this purpose was first proposed by Sapezhko K.M., however, it became widespread only in recent decades. The long-term results of these operations were comparable with those using displaced scrotal and foreskin skin grafts; success is achieved in 85-95% of cases (Bhargava S., Chappie, C.R. 2004, YachiaD., 2007).

At the heart of urethroplasty replacement is the concept of partial or complete replacement of the lumen of the urethra with a tissue flap. As a plastic material, free (devoid of connection with a donor site) and displaced (on the feeding leg) flaps are used.

Free flaps are usually called transplants, and surgery is transplantation; in the case of displaced flaps, the term transposition is used. Both of these methods are used for augmentation (expansion) of the urethra. Among the free flaps (grafts), the most common use was the use of the oral mucosa (buccal and lingual flaps), less commonly used prepuce skin, and among displaced flaps, the preputial and penile flaps on the fascial feeding leg.

Augmentation urethroplasty, which consists in increasing the lumen of the urethra due to a flap longitudinally located as a patch, is recognized as the "gold standard" for one-stage treatment of extended strictures of the urethral bulbos.

In augmentation urethroplasty using a mucosal cheek transplant (buccal graft), the urethra at the stricture level is dissected longitudinally and the graft is fixed as a patch to expand the urethral lumen. Depending on the location of fixation of the buccal graft, the inlay technique and the onlay technique are distinguished.

With the “inlay” option, dissection of the urethral site and fixation of the buccal graft to the feeding bed is performed according to the dorsal semicircle from the inside of the urethra, having previously performed an urethrotomy over the stricture zone along the ventral surface. In the second option, “onlay” - the edges of the graft are fixed to the edges of the mucous membrane of the urethra at the site of the primary section of the urethra. In this case, depending on the mobilization of the urethra and the urethrotomy site, dorsal and ventral techniques are distinguished.

When the dorsal technique is performed, the urethral section affected by stricture is separated from the albumen of the corpora cavernosa and in the area of the urethral lesion they are rotated 180 °. A urethrotomy is made longitudinally going proximal and distal to the stricture into the healthy urethra by 1.5-2.0 cm. The prepared free flap of the mucous membrane of the cheek is fixed to the albumen of the corpora cavernosa. The edges of the dissected urethra are fixed to the edges of the buccal graft. Unlike dorsal, when performing the ventral technique, the urethral bulbous section is isolated only on the ventral (external) surface. The prepared buccal graft is fixed continuously to the edges of the dissected urethra. The tissues of the spongy body are brought down over a fixed graft (Bulbar urethroplasty using buccal mucosa grafts placed on the ventral, dorsal or lateral surface of the urethra: Are results affected by the surgical technique? / G Barbagli [et al.] // J Urol. - 2005 . - Vol. 174. - P. 955-958).

The effectiveness of these operations according to the literature ranges from 85% (Chappie C, Andrich D, Atala A. et al. 2014). The results of the dorsal and ventral method of graft fixation during augmentation of the urethral bulbous region are comparable (Lozano JL, Arruza A. 2015). With the ventral method, the depth and localization of spongiofibrosis is of great importance, since the spongy body of the urethra is in this case the nourishing bed for the transplant and the result of surgical treatment depends on its blood supply.

Surgical interventions in the bulbous (onion) section of the urethra have a rather high percentage of complications that reduce the quality of life of patients, such as leakage of urine after urination and sequestration (pathological accumulation) of sperm, which occur mainly in connection with the formation of a diverticulum. (Long-term follow up of bulbar end-to-end anastomosis: a retrospective analysis of 153 patients in a single center experience / G. Barbagli et al. // J Urol. - 2007. - Vol.178. - P. 2470 -2473).

One of the drawbacks of this operation is the increased elasticity of the buccal graft, which can lead to the formation of a “pseudo-diverticulum” and, consequently, leakage of urine after the act of urination - to the so-called dribbling. Also, with insufficient blood supply to the graft from the feeding spongy body, graft necrosis is possible and, as a result, recurrence of urethral stricture.

A method of surgical treatment of extended urethral strictures is known from the existing prior art (T. M. Zharikova, M. A. Gazimiev, E. A. Bezrukov, A. S. Grechenkov. Technical features of buccal muscle and nerve-saving plasty of the onion urethra. Medical Bulletin Bashkortostan. 2015. Volume 10, No. 3, P. 213-216), including the implementation of ventral urethroplasty, when the bulbospongial muscles are secreted and separated from the spongy body of the bulbous part while maintaining the lateral edges of the muscle attachment and preserving the central tendon of the perineum. The muscles are pulled down and thus the ventral surface of the urethra becomes fully accessible. Using a catheter inserted into the urethra, the distal edge of the stricture is determined, the spongy body is dissected along the midline along the ventral surface, and thus the urethral lumen is visualized. The stricture zone is dissected along its entire length, in addition, the incision is extended further in the proximal and distal directions within healthy tissues (1.5 cm each). After the entire stricture area has been dissected, the length and width of the required urethral site are measured. The mucous cheeks are processed to a suitable size according to the length and width of the urethral site. The two ends of the graft are attached to the proximal and distal corners of the urethrotomy zone, and then a continuous seam of polyglactin 6-0 (or 5-0) creates a tight anastomosis between the left edge of the graft and the left edge of the urethral site. A Foley 16 Ch silicone catheter is inserted. The graft covers the catheter, and then a continuous seam of 6-0 (5-0) polyglactin completes the hermetic anastomosis between the right edge of the graft and the right edge of the mucous membrane of the urethral site. After transplant fixation is completed, the spongy body is sutured over the transplant with single 4-0 polyglactin interrupted sutures. The bulbous spongy muscle is repositioned, covering the spongy body. Fascia Colis, adipose tissue of the perineum and skin are sutured with single absorbable absorbable sutures.

The disadvantage of this technical solution is that the transplant is not fixed to the spongy body, which in the future can lead to a deterioration in the graft engraftment.

A known method of surgical treatment of anterior urethral strictures in men (RF Patent No. 2301024, 06/20/2007), including sequential dissection of the own fascia and bulbocavernous penis muscles and urethral stricture along the surface with a longitudinal section, closing the defect by fixing a patch from an autograft and suturing the postoperative wound, characterized in that after dissection of the penis from the own fascia and bulbocavernous muscles, two flaps form, 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 stitching of the postoperative wound is carried out by tensioning one flap on another with an overlap of 8-10 mm, while the outer edge of the other opposite flap is sutured to the inner surface of one of the flaps, with the creation of tension, over which the flap and fix it to the outer surface of the hemmed flap.

The disadvantage of this method is the free fit of the fascia and muscles to the graft, which does not provide its necessary vascularization. The method of fixation of spongy tissue with this method is not indicated.

A known method of urethroplasty (RF Patent No. 2391921, 06/20/2010) comprising 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 during its narrowing, separating the urethra from the cavernous bodies, and the ventral at the place of its maximum narrowing, increasing the incision of the urethra proximal and distal until the catheter is previously inserted into the urethral lumen, the dorsal graft is used as the main graft, and the ventral graft is additional, with an additional graft form from the mucous membrane of the tongue.

The disadvantage of this method of urethroplasty is the lack of additional fixation of the transplant to the spongy body, which increases the possibility of recurrence of the disease.

The prototype of the proposed method, we selected the technique described in the work - S. Kotov. Urethral strictures in men. The choice of urethroplasty. (Moscow, 2018, p. 80-81), which provides for a longitudinal dissection of the urethra along its ventral surface, stitching of a buccal graft to the edges of the resected urethra, suturing of the spongy body tissue along Donati with graft graft through one suture. This method is aimed at preventing dribbling of urine (leakage of urine after urination).

However, the disadvantage of this method is the insufficient fit of the graft to the tissues of the spongy body, which can lead to complications such as ischemia and necrosis of the buccal graft, leading to the development of severe inflammatory complications with the subsequent development of relapse of stricture and urethrodermic fistula.

The task to which the invention is directed is to develop a more effective method for urethral reconstruction in men by improving vascularization of the buccal graft and thereby reducing the number of postoperative complications and relapses of urethral strictures.

The problem is achieved in that in this method of surgical treatment of extended strictures of the bulbar section of the urethra in men after longitudinal dissection of the affected area of the bulbar section of the urethra along the ventral surface, a buccal graft is inserted with the mucosal surface inward on Foley catheter No. 20 Ch, the edge of the urethra is stitched with the edges of the graft, using monocryl 4/0 with a needle 17 mm long, a continuous seam. Then, the urethral catheter is replaced with a metal bougie No. 20 Ch, the edges of the dissected spongy body above the graft are compared and sutured with separate interrupted sutures with a 4/0 monocryl with a 17 mm long needle with a buccal graft with a step frequency of 5 mm and also parallel to the suture line on both sides spongy body tissues are stitched with a buccal graft grasp with a step frequency of 5 mm, longitudinally with respect to the spongy body incision line, then the bougie is replaced with a Foley catheter No. 16.

The invention is illustrated in the diagrams of FIG. 1 and FIG. 2. In FIG. Figure 1 shows the stapling of the graft with the urethra, where 1 is the edge of the buccal graft, 2 is the edge of the tissue of the spongy body, 3 is the tissue of the urethra, 4 is the stitching of the tissue of the spongy body with the graft of the buccal graft.

FIG. 2 is a diagram of spongy body tissue suturing with picking up a buccal graft with a step frequency of 5 mm, longitudinally with respect to the cut line of the spongy body.

The technical result provided by the given set of signs is to reduce the number of postoperative complications and relapses in patients with extended strictures of the urethral bulbous region, eliminating tissue ischemia in the area of the graft adjacent to the spongy tissue.

This result is achieved by fixing the buccal graft with additional sutures from a long-absorbable suture material to the spongy body, which provides the graft with nutrition, support and prevents the formation of hernial protrusion. Replacing the catheter with a metal bougie provides intraoperative monitoring of the complete flashing of the spongy body together with the graft and protection against accidental flashing of the opposite wall of the urethra or catheter.

The use of suture material monocryl 4/0 with a needle 17 mm long allows for less traumatic fusion of the graft to the urethra and spongy body.

Sewing tissues of the spongy body with graft grasp with a step frequency of 5 mm allows not only to provide the necessary and sufficient vascularization of tissues, but also to perform the role of a skeleton for the newly formed urethra.

The longitudinal location of the second line of sutures with respect to the incision line of the spongy body can significantly reduce the risk of corrugation of the graft and narrowing of the lumen of the urethra.

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

The method is as follows.

The operation is performed under endotracheal anesthesia. Access is perineal. The patient’s position is a lithotomy position, which implies laying the patient so that his buttocks are at the end of the table, his legs are raised, divorced and laid on special supports.

After processing the surgical field, cystotomy is performed. Through a cystotomy incision into the posterior urethra, bougie No. 22 Ch is carried out until the proximal border of the urethral stricture is determined. Through the external opening into the urethra, bougie No. 22 Ch is carried out to the distal stricture border.

Perform a linear incision of the skin and underlying perineal tissue up to 10 cm long in the projection of the urethra. By accessing the urethra, the superficial fascia of the perineum and bulbocavernous muscles are dissected. In a sharp way, focusing on the peripheral bougie, the spongy body is dissected, the urethra is secreted and intersected in the area of the distal stricture border along the ventral surface to the proximal stricture border, which is clarified using the bougie No. 22 Ch passed through the cystostomy opening. A urethral catheter No. 20 Ch is installed, the length of the stricture is finally specified.

At this stage, a buccal graft is taken from the oral cavity according to a generally accepted technique. Its width is usually 1.5 cm, and the length is determined by the length of the stricture plus an additional 20%, due to the possible reduction of the graft after its collection.

After standard processing of the graft, it is placed in the defect of the urethra, with the mucous surface inside (Fig. 1). The edge of the urethra (Fig. 1, pos. 3) is stitched with the edges of the buccal graft (Fig. 1, pos. 1) using monocryl 4/0, a 17 mm long needle, a continuous suture. Then the urethral catheter is replaced with a metal bougie No. 20 Ch, the edges of the tissue of the spongy body (Fig. 1, item 2) above the graft are matched and sutured with separate nodal sutures with a 4/0 monocryl needle 17 mm long with a buccal graft grasp with a step frequency of 5 mm and on both sides parallel to the suture line, the spongy body tissue is stitched with a buccal graft with a step frequency of 5 mm, longitudinally with respect to the spongy body incision line (Fig. 1, pos. 4; Fig. 2). The bougie is being replaced with a Foley catheter No. 16. Hemostasis is monitored. Bulbospongial muscles are reduced, single nodal sutures of vikril 3/0 are superimposed on them. Fascia, adipose tissue and skin are sutured in layers with single knotted vikril 3/0 sutures. A pressure bandage is applied.

The catheter is removed on day 21 with the mandatory performance of pericatheter urethrography.

The practical applicability of the proposed method is illustrated by examples from clinical practice. Example 1

Patient Mr., 50 years old, Received 04.04.18 with complaints of difficulty urinating with a sluggish stream. In 2005, the patient suffered gonorrhea urethritis.

Over the past year, a gradual weakening of the stream of urine was noted. An examination revealed a stricture of a 4.5 cm urethral bulbous section of the urethra. After the preoperative preparation on 04/06/18, an operation was performed - urethroplasty using a buccal graft according to the claimed method. After hemming along the perimeter of the graft to the resected edges of the urethra, hemming of the spongy body brought down over the graft was performed with buccal graft grafting on metal bougie No. 20 Ch previously inserted into the urethra with single seams 4/0 monocryl with a 17 mm long needle, then individual monocril 4 sutures were superimposed 4 / 0 with a needle 17 mm long with graft grasp with a step frequency of 5 mm on both sides, longitudinally with respect to the incision line of the spongy body. The postoperative period was uneventful, without features. The perineal wound healed by primary intention. Epicystostomy drainage was removed on the 8th day, sutures on the perineum were removed on the 9th day after the operation. On the 21st day, the urethral catheter was removed. Restored self-urination. During the control examination after 3, 6 and 12 months. - there is no data for a stricture recurrence.

Example 2

Patient Sh-s, 61 years old. He entered the clinic on 01/11/18 with complaints of difficulty urinating with a sluggish stream, a feeling of incomplete emptying of the bladder after an act of urination. From the anamnesis, it is known that after surgery on the veins of the lower extremities against the background of an installed urethral catheter, the patient developed acute urethritis. After 1.5 months, the patient began to notice marked difficulty urinating. The patient was repeatedly performed internal optical urethrotomy with a short effect. An examination in the clinic revealed a recurrent stricture of the bulbous section of the urethra 3 cm long. On January 20, 2018, the patient underwent surgery: augmentation urethroplasty using a buccal graft according to the claimed method. After hemming along the perimeter of the graft to the resected edges of the urethra, hemming of the spongy body brought down over the graft was carried out with the buccal graft grasped on a metal bougain No. 20 Ch previously inserted into the urethra with single seams 4/0 monocryl with a 17 mm long needle, then individual monocril 4 stitches were applied with monocryl 4 / 0 with a needle 17 mm long with a grasp of a flap with a step frequency of 5 mm on both sides, longitudinally with respect to the incision line of the spongy body. The postoperative period was uneventful. The wounds of the perineum and the anterior abdominal wall healed by primary intention. Skin sutures were removed on the 8th day. Epicystostomy drainage was removed on the 9th day, the urethral catheter on the 21st day, after which independent adequate urination was restored. With control urethrography after 3 months. - patency of the urethra is not broken. A follow-up examination after 6, 12 and 18 months of data for a recurrence of stricture did not reveal.

According to the claimed methodology, we operated on 15 patients for the period 2017-2019. No postoperative complications and relapses were observed. In all patients, independent adequate urination was restored.

The inventive method improves the efficiency of urethroplasty in comparison with the known due to:

возможности коррекции стриктур передней уретры большой протяженности;

the possibility of correction of strictures of the anterior urethra of great length;

более надежного укрепления вентральной поверхности уретры;

more reliable strengthening of the ventral surface of the urethra;

улучшение кровоснабжения в зоне прилегания трансплантата к спонгиозной ткани.

improved blood supply in the area of the graft to spongy tissue.

The advantages of the proposed method for the surgical treatment of extended strictures of the bulbous urethral section in men consists in the fact that it allows eliminating tissue ischemia in the area of the graft adjoining spongy tissue, reducing the number of postoperative complications, eliminating relapses of the disease, restoring independent adequate urination, and thereby improving the quality of life patients.

Claims (1)

A method for the surgical treatment of extended strictures of the urethral bulbous region in men, including longitudinal dissection of the urethra along its ventral surface and suturing of the buccal graft to the edges of the resected urethra, characterized in that the buccal graft has a mucosal surface inside and stitching with the edges of the urethra along the ventral surface of the affected area the urethral section is produced with a continuous suture on a Foley catheter No. 20 Ch, using monocryl 4/0 with a needle 17 mm long; after which the urethral catheter is replaced with a metal tuft No. 20 Ch, the edges of the tissues of the dissected spongy body above the graft are compared and sutured with separate interrupted sutures with a 4/0 monocryl with a 17 mm long needle with a buccal graft with a step frequency of 5 mm, parallel to the suture line on both sides the spongy body tissues are stitched with graft pickup with a step frequency of 5 mm, longitudinally with respect to the spongy body cut line, then metal bougie No. 20 Ch is replaced with a Foley catheter No. 16.

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