RU2771271C1 - Method for surgical management of extended strictures of spongy urethra - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to urology. Dorsal augmentation of a spongy urethra is performed with a buccal graft through a ventral sagittal urethrotomy approach. Round hole is formed along the midline in the buccal graft at 1.0 cm from its proximal edge, the edges of which are sutured to the edges of the proximal urethral opening. Distal end of the graft and its lateral edges are connected to the edges of the dorsal urethral incision. Proximal end is with skin incision edges, after which graft throughout its area, separate interrupted sutures are fixed to the underlying tissues and the edges of the ventral urethra incision are sutured with the edges of the skin incision, and 6–8 months later, the urethra is tubularized by suturing on the urethral catheter the edges of the incision bordering the buccal graft and the urethral site.EFFECT: method enables to form a normal lumen of the urethra with extended strictures of the spongy urethra, improve the quality of life of patients, reducing the risk of developing stenoses in the proximal anastomosis of the urethra with a buccal graft.1 cl, 1 dwg, 2 ex

Description

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

Strictures of the spongy urethra in most cases are subject to augmentation or replacement urethroplasty. Resection techniques are applicable only for short lesions of the bulbar segment of the urethra, while extended lesions of the penile and bulbar urethra require the use of plastic surgery techniques.

A. Orandi (Fernandes M, Orandi A, Draper JW. Urethroplasty: a new method of closure. J Urol. 1966;96(5):779-83) proposed his method of penile urethra augmentation in 1966. For its implementation, a longitudinal flap of the skin of the penis is used, which is sutured to the edges of the longitudinally dissected urethra. The operation is relatively simple to perform and has been used to date. However, the technique has disadvantages inherent in all skin plastics - marginal necrosis of the skin flap with the formation of urinary fistulas, pseudodiverticula, and hair follicles serve as a source of hair growth, on which stones subsequently form.

Due to the shortcomings of skin flaps, grafts of the oral mucosa are now widely used.

A known method of urethroplasty, including performing ventral and dorsal augmentation of the anterior urethra with the formation of grafts, primary and secondary, when performing dorsal augmentation, the graft is formed from the buccal mucosa, characterized in that dorsal augmentation of the anterior urethra is carried out throughout its narrowing, separating the urethra from the cavernous bodies, and the ventral one - in the place of its maximum narrowing, increasing the incision of the urethra proximally and distally until the mobility of the catheter previously inserted into the lumen of the urethra appears, the dorsal graft is used as the main one, and the ventral one is additional, and the additional graft is formed from the mucous membrane of the tongue (RF patent No. 2391921, published 06/20/2010).

The main disadvantage of this method is the excessive trauma of the oral cavity, associated with a high risk of bleeding, since the grafts are taken from two sites, one of which is the sublingual region, in which a large number of arterial vessels are anatomically located. The need for two grafts can also lead to scarring and disease recurrence due to additional anastomoses.

A known method of surgical treatment of extended strictures of the bulbar urethra in men, including a longitudinal dissection of the urethra along its ventral surface and suturing a buccal graft to the edges of the resected urethra, characterized in that the buccal graft is located on the mucous surface inside and sutured to the edges of the urethra along the ventral surface of the affected area the bulbar urethra is made with a continuous suture on a Foley catheter No. 20 Ch using monocryl 4/0 with a needle 17 mm long; after that, the urethral catheter is replaced with a metal bougie No. 20 Ch, the edges of the tissues of the dissected spongy body above the graft are compared and sutured with separate interrupted 4/0 monocryl sutures with a 17 mm long needle, capturing the buccal graft with a step frequency of 5 mm, on both sides parallel to the suture line the tissues of the spongy body are sutured with the graft picked up at a step frequency of 5 mm, longitudinally relative to the incision line of the spongy body, then the metal bougie No. 20 Ch is replaced with a Foley catheter No. 16 (RF patent No. 2723744, publ. 06/17/2020).

The disadvantages of this method include the possibility of using only within the bulbous segment of the spongy urethra, as well as a high probability of narrowing the urethra due to the upper row of sutures on the spongy body of the urethra, which, in fact, can reduce the effectiveness of surgery that creates folding of the graft.

The prototype of the claimed method is the augmentation dorsal inlay plastic with a buccal graft developed by H.S. Asopa et al. (Asopa HS, Garg M, Singhal GG, Singh L, Asopa J, Nischal A. Dorsal free graft urethroplasty for urethral stricture by ventral sagittal urethrotomy approach. Urology. 2001;58(5):657-9). The principle of the operation consists in longitudinal dissection of the urethra both along the ventral and dorsal surfaces with the formation of a platform on the surface of the albuginea of the cavernous bodies, to which the buccal graft is fixed. This technique is easy to perform, and its main advantage is the absence of the need to mobilize the dorsal wall of the urethra, which eliminates trauma to the arteries supplying the urethra and prevents tissue ischemia. This technique is applicable for strictures of the spongy urethra, both bulbar and penile segments.

The disadvantages of the prototype method include:

- the impossibility of creating an adequate lumen of the urethra when the width of the urethral platform is less than 1.0 cm;

- a relatively high risk of intraoperative bleeding associated with the possibility of perforation of the cavernous bodies of the penis due to the fact that urethral augmentation in the areas of the proximal and distal openings is carried out from the side of the mucosa from the lumen of the urethra, while suturing the cavernous bodies from this access is difficult to implement;

- a relatively high probability of developing stenosis and progression of stricture disease in the areas of proximal and distal anastomoses of the urethra with a transplant due to the fact that urethral augmentation in these areas is carried out only along its dorsal semicircle.

The objective of the claimed invention is the treatment of extended strictures of the spongy urethra and the reduction of the risk of developing stenosis in the area of the proximal anastomosis of one's own urethra with a buccal graft.

The problem is solved by performing dorsal augmentation of the spongy urethra with a buccal graft through the ventral sagittal urethrotomy access; in the buccal graft, at a distance of 1.0 cm from its proximal edge, a rounded hole is formed along the midline, the edges of which are sutured to the edges of the proximal opening of the urethra, the distal end of the graft and its lateral edges are connected to the edges of the dorsal incision of the urethra, the proximal end - to the edges of the skin incision, after which the graft over its entire area is fixed to the underlying tissues with separate interrupted sutures and the edges of the ventral incision of the urethra are sutured with the edges of the skin incision, and after 6-8 months the urethra is tubularized by stitching the edges of the incision bordering the buccal graft and urethral pad.

The technical result of the invention is:

- formation of a normal lumen of the urethra with extended strictures of the spongy urethra through the use of a buccal graft that augments the dorsal semicircle of the narrowed urethra;

- improving the quality of life of patients by restoring natural urination;

- reducing the risk of developing stenosis in the area of the proximal anastomosis of the urethra with the graft due to augmentation that performs the entire circumference of this area and provides an increase in the internal lumen of the urethra in this area.

The claimed invention is illustrated in figure 1, showing the location and fixation of the buccal graft to the urethra and structures of the penis, where: 1 - buccal graft; 2 - urethral platform; 3 - the edges of the dorsal incision of the urethra; 4 - edges of the ventral section of the urethra; 5 - skin of the penis; 6 - edges of the skin incision; 7 - proximal opening of the urethra; 8 - distal opening of the urethra.

Detailed description of the method and examples of its clinical implementation.

The method is carried out in two stages. The technique of the operation involves surgical intervention on the urethra and in the oral cavity. The operation can be performed by one surgical team or by two at the same time (the second team for graft sampling reduces the duration of the operation). At the first stage, through the ventral sagittal urethrotomy access, augmentation of the dorsal semicircle and proximal opening of the narrowed urethra is performed, at the second

- tubularization of the urethra. The period between the first and second stage of treatment is 6-8 months. Anesthesia at the first stage of treatment is combined (spinal + nasal endotracheal intubation), at the second - spinal. The position of the patient on the operating table is on the back.

The first stage of treatment is the augmentation of the dorsal semicircle and the proximal opening of the narrowed urethra. A buccal graft is preliminarily harvested. The oral cavity is treated with a solution of Miramistin 0.02%, an oral retractor (Dingmann) is installed. The salivary gland duct (Stensen's canal) is visualized, located at the level of the second painter, in order to prevent its damage. Using a surgical marker, the boundaries of the buccal graft are marked, commensurate in length with the length of the urethral stricture and at least 3.0 cm wide. For the purpose of hemostasis, a 1.0% solution of novocaine with epinephrine (1: 100,000) is injected along the boundaries of the designation. Using a scalpel and scissors, a rectangular graft is cut out in a sharp way within the submucosal layer, it is cleaned from fragments of fatty tissue until the submucosal layer is exposed. Perform hemostasis of the donor site, the defect of the oral mucosa is sutured with a continuous suture (vicryl 5/0). In the proximal part of the graft, 1.0 cm away from its edge, a rounded hole is formed along the midline with a scalpel, the diameter of which should correspond to the diameter of a healthy proximal urethral opening. The graft, before using it at the stage of urethroplasty, is placed in saline.

Through the meatus, a metal bougie No. 20 Ch is passed into the urethra, thereby determining the distal border of the stricture. Above the narrowed urethra, a longitudinal incision of the skin and underlying tissues is performed. The urethra in the stricture zone is dissected by a longitudinal median incision along its ventral semicircle to a normal lumen. Further, from the side of the mucous membrane along the midline of the dissected stricture urethra, a second longitudinal dissection of the urethra is performed along the dorsal semicircle through all its layers to the albuginea of the cavernous bodies. With strictures of the bulbar urethra, the bottom of the incision of the dorsal wall of the urethra is the muscular aponeurotic structures of the intercrural space. The edges of the dorsal incision of the urethra are partially mobilized from the underlying tissues on both sides by 0.1-0.2 cm, thereby creating a platform for placing the buccal graft. With the help of a ruler, the longitudinal and transverse dimensions of the created area are measured, which should provide an adequate lumen of the urethra in the future (22 - 24 Ch). A buccal graft with a mucosal surface comparable in size is placed on the platform and straightened into the lumen of the urethra. The edges of the hole formed in the graft are sutured with separate interrupted sutures (5/0 vicryl) to the edges of the proximal urethral opening, and the distal end of the graft and its lateral edges are connected to the edges of the dorsal urethral incision, the proximal end - to the edges of the skin incision. Further, the graft over its entire area, with separate interrupted sutures in a checkerboard pattern, is fixed to the underlying albuginea of the cavernous bodies or to the muscular-aponeurotic structures of the intercrural space. The final stage of the operation is the suturing of the edges of the ventral incision of the urethra with the edges of the skin incision (Fig. 1). In the case of a pronounced cicatricial change in the urethra and the width of the urethral area is less than 1 cm, it is completely excised, and the lateral edges of the graft are anastomosed directly with the edges of the skin incision. To divert urine through the urethra into the bladder, a Foley catheter No. 18 Ch is passed through the urethra, which is kept for up to 7 days.

The second stage of treatment is tubularization of the urethra. An incision is made surrounding the buccal graft and the urethral platform. A Foley catheter No. 18 Ch. is inserted through the urethra into the bladder. On the catheter, separate interrupted sutures (5/0 vicryl) form the ventral semicircle of the urethra, in the proximal section, due to the stitching of the lateral edges of the graft, in the distal, - own urethra. Hemostasis is performed, the skin wound is sutured in layers. The urethral catheter is kept for 14-17 days, then spontaneous urination is restored.

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

Example 1. Patient G-s, 28 years old. He considers himself ill for more than 10 years, when he first began to notice complaints of difficulty urinating, a weak stream of urine, a feeling of incomplete emptying of the bladder. She has a history of an episode of acute urinary retention, which was resolved by epicystostomy. An extended stricture of the penile urethra was diagnosed. Performed surgery in volume: urethroplasty of the penile urethra using a skin flap. After 11 months, he noted an increase in dysuric symptoms, a recurrent extended stricture of the penile urethra was diagnosed. In the clinic of urology of the Rostov State Medical University, an operation was performed according to the claimed method.

In the zone of narrowing, the urethra is longitudinally dissected along the ventral and dorsal semicircles to a normal lumen. The defect of the urethra was 6.0 cm. The edges of the dorsal incision of the urethra were mobilized from the albuginea of the penis by 0.2 mm, thereby creating a platform for placing the buccal graft. In the prepared buccal transplant measuring 6.0×3.0 cm, 1.0 cm away from its proximal edge, a rounded hole was formed along the midline, which corresponded in diameter to the proximal urethral opening - 24 Ch. The edges of the graft opening are sutured to the edges of the proximal urethral opening, augmenting it around the entire circumference. The edges of the dorsal incision of the urethra are anastomosed with the edges of the graft, the edges of the ventral incision of the urethra are anastomosed with the edges of the skin incision. A Foley catheter No. 18 Ch was installed in the bladder along the urethra, which was removed after 7 days, restoring urination through the formed external opening of the urethra.

The second stage of surgical treatment was performed 6 months after the first. An incision was made bordering the buccal graft and the urethral platform. The edges of the incision are sutured with separate interrupted sutures (vicryl 5\0) on the urethral Foley catheter No. 18 Ch, conducted into the bladder, thereby forming the ventral semicircle of the urethra. The wound is sutured in layers. Postoperative proceeded smoothly. The sutures were removed on the 6th day, the wound healed by primary intention. Urination was restored on the 14th day, the maximum urine flow rate was 24.1 ml/s. The patient was discharged with recovery.

Example 2. Patient M-ev, 32 years old. In August 2019, after acute urethritis, he noted a deterioration in the quality of urination, and a stricture of the penile urethra was diagnosed. In the clinic of urology of the Rostov State Medical University performed surgical treatment according to the claimed method.

The narrowed portion of the urethra is longitudinally dissected along the ventral and dorsal semicircles to a normal lumen. The length of the stricture was 4.5 cm. A platform was created on the surface of the albuginea of the cavernous bodies to place the buccal graft. A buccal graft sized 4.5×3.0 cm was prepared. In its proximal part, along the midline, 1.0 cm away from the edge, a rounded opening with a diameter of 26 Ch was formed, corresponding to the lumen of the proximal opening of the urethra. The edges of the graft opening are sutured to the edges of the opening of the proximal opening of the urethra, thereby augmenting the entire circumference of the urethra. The edges of the dorsal incision of the urethra are anastomosed with the edges of the graft, the edges of the ventral incision of the urethra are anastomosed with the edges of the skin incision. A Foley catheter No. 18 Ch was installed in the bladder along the urethra, which was removed on the 7th day after the operation, urination was restored.

After 8 months, the second stage of treatment was performed, during which an incision was made bordering the buccal graft and the urethral platform. On a Foley catheter No. 18 Ch, inserted into the bladder, the edges of the incision were sutured with separate interrupted sutures (5/0 vicryl), and a ventral semicircle of the neourethra was formed. The postoperative period is smooth. The sutures were removed on the 6th day, the wound healed by first intention. Urination was restored on the 14th day, the maximum urine flow rate was 28.6 ml/s. The patient was discharged with recovery.

According to the claimed method, we operated on 14 patients for the period 2016-2021. All patients restored independent adequate urination. There were no postoperative complications or recurrences of the disease.

The main advantages of the proposed method:

- the method allows to correct extended strictures of the spongy urethra and restore up to 10 cm of the urethra;

- the method allows to form an adequate lumen of the urethra when the width of the urethral platform is less than 1.0 cm or its complete absence;

- the method allows you to save the blood supply to the dorsal wall of the urethra and underlying structures by eliminating excessive mobilization of the urethra;

- the method allows to reduce the risks of intraoperative bleeding associated with perforation of the cavernous bodies of the penis due to the fact that the fixation of the graft in the area of the proximal opening is carried out from the side of the mucosa from the lumen of the urethra;

- the method makes it possible to prevent narrowing of the urethra during the formation of its ventral semicircle in the area of the proximal anastomosis with the graft due to the augmentation of the urethra produced along the entire circumference;

- the method allows to reduce the risks of developing stenosis in the area of the proximal anastomosis of the urethra with a transplant due to the augmentation of this area around the entire circumference of the urethra.

The claimed method of surgical treatment of extended urethral strictures has been tested on sufficient clinical material and can be recommended for use in urological hospitals.

Claims (1)

A method for surgical treatment of extended spongy urethral strictures, including dorsal augmentation of the spongy urethra with a buccal graft through the ventral sagittal urethrotomy access, characterized in that in the buccal graft, 1.0 cm away from its proximal edge, a rounded hole is formed along the midline, edges which is sutured to the edges of the proximal opening of the urethra, the distal end of the graft and its lateral edges are connected to the edges of the dorsal incision of the urethra, the proximal end - to the edges of the skin incision, after which the graft over its entire area is fixed to the underlying tissues with separate interrupted sutures and the edges of the ventral incision are sutured urethra with the edges of the skin incision, and after 6-8 months, the urethra is tubularized by suturing the edges of the incision on the urethral catheter, bordering the buccal graft and the urethral platform.

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