RU2665545C1 - Method of surgical treatment of proximal hypospadias - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to urology, to the treatment of proximal hypospadias in boys. Method comprises a circumcision section with isolation of the native meatus and urethral area on a penis stem. Penis skin is separated together with a fleshy shell adjacent thereto from Baca fascia. When providing an artifactual erection of the penis curvature of more than 30° is visualized and dorsal plication of cavernous bodies leads to a pronounced shortening of the penis length, urethral pad is crossed directly under the balanus by continuing the circumcision incision. Then the left urethral area is mobilized from the cavernous bodies and ventral corprotomy is performed. Free graft of the preputium inner leaf is produced. And the preserved urethral area is tubularized on the catheter of an age diameter. Tubular segment of the artifactual urethra is fixed to the cavernous bodies and only then the graft from the preputium inner leaf is fixed from the displaced distal meatus to the balanus. After 6 months from the first intervention, the prefabricated flap is excised by the fringing incision and tubularized on the catheter of an age diameter.EFFECT: method of surgical treatment of proximal hypospadias is proposed.1 cl, 2 ex, 9 dwg

Description

The invention relates to medicine, namely to urology, pediatric urology - andrology and can be used in the surgical treatment of proximal hypospadias in boys.

Hypospadias is one of the most common malformations of the male genital organs. A frequency of 1 in 300 newborn boys is traditionally cited (Manzoni G, Bracka A, Palminteri E, Marrocco G. Hypospadias surgery when, what and by whom. BJU Int 2004; 94: 1188-95). However, epidemiological evidence suggests that in developed Western countries the incidence is increasing and may reach 8 per 1000 newborn boys (Paoluzzi LJ. Is. Hypospadias an 'environmental' birth defect? Dialogues Pediatric Urol 2000; 23: 2-4) .

Most often, hypospadias is defined as a malformation of the anterior urethra. However, changes can affect almost all penile tissue. Thus, a broader definition of this disease can be made. Hypospadias is a complex congenital malformation of the external genitalia in boys, in which a combination of changes is determined to varying degrees, such as splitting of the foreskin, dysplasia and deficiency of the skin of the penis, displacement of the external opening of the urethra proximal from the head to the perineum, dysplasia of the tubular native urethra , penile curvature, hypoplasia and / or dyspalasia of the corpora cavernosa and penis, splitting and transposition of the scrotum.

Therefore, the issue of surgical surgical treatment of hypospadias in boys remains relevant.

More than 300 modifications and methods for surgical correction of hypospadias are known and none of them is universally recognized. (Altarac S, Pape_s D, Bracka A. Two-stage hypospadias repair with inner preputial layer Wolfe graft (Aivar Bracka repair). BJU Int 2012; 110: 460e73).

A known method for the correction of distal stem hypospadias (RF patent No. 2199954, application No. 2000102449, priority date 02/03/2000, publication date 03/10/2003, IPC class A61B 17/00), which includes two stages, in this case, a skin incision is performed at the first stage, bordering the head of the penis, along the edge of the coronary sulcus, continue it longitudinally along the ventral surface of the penis to the hypospadias of the penis with the bordering of the latter and preservation of the skin "collar", mobilize the skin around the trunk of the penis to the stem-cervical angle, fibrous cords are excised along the ventral surface of the penis until it is fully straightened, then in the center of the mobilized skin, a through longitudinal incision is made, departing from the symphysis-stem angle by a distance equal to the length of the penile shaft, the penis head is brought out through the incision and the skin edges are sutured in the coronal groove with the edges a through incision, after which the excess mobilized skin with prepuce is moved to the ventral surface of the penis with a cross-shaped incision above the hypospadias and the location and the excess of prepuce is proximal to the meatus, the edges of the incision are sutured with the edges of the skin collar, and the edges of the mobilized skin are sutured with the edges of the wound on the ventral surface of the penis, after 6 months the second stage is performed, in which the articular urethra is formed from the prepuce, immersing the meatus in it, rotate the formed urethra in the distal direction and is fixed at the top of the head.

The disadvantages of this method: 1. excision of the urethral site, tissues, maximally histological structure close to the normal urethra, which affects the hydrodynamic properties of the artifact urethra. 2. The artificial urethra is not fixed along the ventral surface to the cavernous bodies, which can lead to its displacement and balancing during urination, as well as a higher risk of the formation of such a complication as urethral diverticulum, which may require repeated surgical intervention.

A known method of surgical treatment of hypospadias in boys (patent No. 2435527, application No. 2009146766, priority date 12/15/2009, IPC class A61B 17/00). The known method consists in the fact that a skin incision is made that borders the glans penis, a midline section of the urethral site, simultaneous restoration of the missing section of the urethra using local tissues, restoring the integrity of the urethra, creating an external opening of the urethra with subsequent covering of the skin defect on the penile shaft and suturing wounds. At the same time, at the beginning of the operation, a circular incision is made of the skin of the trunk of the penis along the lower edge of the split foreskin to the urethral site, then a skin incision is made proximal to the external opening of the urethra (meatus) by 2 mm with the cutting of the urethral area from the meatus to the top of the glans penis 8- wide 12 mm, then along the edge of the border between the outer and inner sheets of the foreskin, the skin is dissected, followed by de-epithelization of the inner leaf of the foreskin, tubes are formed from the urethral site ku, pre-dissect it along the middle in the proximal section below the meatus by 2-3 mm, while crossing the meatal bridge, form a Y-section in the distal section at the top of the head, separate the middle (fleshy) leaf of the foreskin from the skin to the level previously produced skin incision along the lower edge of the split foreskin circumferentially to the urethral site, cut the skin of the outer sheet along the edge of this incision, apply the first suggestive suture to the distal neourethra, produce chenie deepitelizirovannogo flap is dissected in the middle formed deepitelizirovanny flap on a vascular pedicle middle leaf of the foreskin and moved along the side surfaces of the penis to the ventral part, and these flaps deepitelizirovannymi foreskin harboring neouretru on both sides.

The disadvantage of this method is that this method can be used only for the treatment of distal (lung) forms of hypospadias, in which there is no curvature of the penis.

Surgeons crossing the urethral site then completely remove it, and in the method we offer, we save it and form part of the urethra from it.

The inventors used two well-known approaches to solving the claimed problem, combining them and improving.

The proposed Warren Snodgrass (the first known method) modification of tubularization of the urethral site with its preliminary dissection for distal hypospadias was initially considered as an attempt to improve the cosmetic results of the treatment of mild hypospadias, namely the desire to form an anatomically normal meatus (W. Snodgrass, N. Bush. Hypospadiology. Dallas: Operation happenis, 2015, Tubularized incised plate urethroplasty for distal hypospadias. W, Snodgrass. 1994, Journal of Urology, T. 151, p. 464).

The author himself presented the idea of creating a technique, in the later descriptions, as a random combination of surgical techniques known at that time for hypospadias, which yielded a good result, and most importantly a simpler technique without using “onlay” and preserving the urethral area. After some time, this operation began to be used to correct the proximal forms of the defect. Thus, the extended artifact urethra was created entirely from the urethral site.

Subsequently, W. Snodgrass's work entitled “Tubularized incised plate urethroplasty for distal hypospadias” (TIP) became the most cited technical publication in the world. And W. Snodgrass himself is currently the most cited specialist hypospadologist in more than half a century of history, 10 of the 150 most cited articles in the world.

K, Cuckow PM. 2006 г., European Urology, T. 50(2), стр. 366.)The second method is the technique proposed by Aivar Bracka, which was originally used, including by the author himself, for the correction of hypospadias in previously operated patients. Subsequently, the method found its supporters for the correction of proximal forms of hypospadias in primary patients (Surgical correction of severe hypospadias. Kagantsov, IM; The two-stage repair for severe primary hypospadias .. Johal NS, Nitkunan T,

K, Cuckow PM. 2006, European Urology, T. 50 (2), p. 366.)

The first stage of the Bracka operation involves excision of tissues from the hypospadias to the coronary sulcus, dissection of the glans penis along the midline with mobilization of the “wings” of the head, transplant of the inner foreskin sheet (without blood supply) of the desired configuration, moving the latter to the position of the future urethra, replacing the defect on the ventral surface of the penis from the meatus to the top of the head with a prepared graft. The second stage of the operation is a variant of the Duplay operation, the flap from the foreskin previously transferred to the ventral surface is secreted with the capture of the meatus and tubularized on the catheter. The followers of this method, in turn, also try to improve the results of treatment by changing the previously described surgery technique. For example, it is proposed: the inner sheet of the foreskin in the form of a free transplant is repeatedly punched with a 18 G needle before it is fixed on the ventral surface, which, according to the authors, reduces the likelihood of hematoma accumulation under it, and also increases the transplant area. The second stage of the operation can be performed as a TIP operation with proximal hypospadias with the application of a longitudinal relaxing incision along the midline of the flap prepared for tubularization (mainly in its distal part), which, according to the authors, reduces the tension of the suture line and helps prevent the formation of complications such as fistulas and stenosis urethra.

Despite the fact that many surgeons prefer to use the inner sheet of the foreskin in the form of a free transplant for the first stage of Bracka surgery, the question of using the oral mucosa as a plastic material remains relevant. More often, this method finds its application in the correction of hypospadias in patients who have undergone surgical treatment and received certain complications, the material can be taken from the cheek or lower lip, the operation is technically similar to the previously described.

An intermediate option between the TIP method and Bracka was a technique in which a defect formed after dissection of the urethral site was replaced by a free graft of the buccal mucosa. Now this method is more often used using the inner sheet of the foreskin as a plastic material, for simultaneous hypospadias plasty without pronounced curvature of the penis, but a narrow urethral area and is interpreted as an improved modification of the TIP operation, called GTIP (letter G from the English graft graft) or "Snodgraft." The authors using this method believe that the defect formed during dissection of a narrow urethral site is quite large and there is a higher risk of scarring in the postoperative period, so it requires additional replacement with a sheet of foreskin.

None of the methods described above effectively solves the issue of treatment of proximal hypospadias in boys.

Treatment of severe hypospadias remains a serious surgical problem, with one-stage techniques often associated with the development of complications, which can reach 20-50%.

The technical result of the invention is to increase the effectiveness of treatment by creating part of the artifact urethra with better than “cutaneous” urethra properties and shortening the length of the skin urethra.

Previously known experience in creating an artifact urethra from the skin of the penis, whether it is the foreskin, trunk skin, and so on, led to the conclusion that the “skin” urethra differs from the native urethra in hydrodynamic characteristics. As practice has shown, the urethra is not just a “tube” that removes urine from the bladder, but an organ with unique properties. At the same time, a similarity was found histologically in the cytoarchitectonics of the urethral site and the native urethra.

In adult men who underwent surgery for proximal hypospadias in childhood, negative symptoms such as stagnation of urine and ejaculate in an extended artifical urethra created from the skin were found. Possessing other elastic properties, the “skin” urethra was not able to contract like a healthy urethra.

The method of surgical treatment of proximal hypospadias that we offer does not contradict the algorithm described above and is a variant of a two-stage surgical intervention.

The improvement is aimed at improving the properties of the artifactal urethra and reducing the negative effects of poor resistance of the artifical urethra, such as stagnation of urine and ejaculate.

A method is proposed for surgical treatment of proximal hypospadias, including a circumcision incision with the release of the native meatus and the urethral site on the penile shaft, the skin of the penis, along with the meaty membrane adjacent to it, from the fascia of the Bucca, when more than 30 penile curvature is visualized when creating an artifact erection dorsal plication of cavernous bodies will lead to a pronounced shortening of the length of the penis, the urethral area is crossed directly under the head of the polo of the penis by continuing the circumcision section, then the left urethral site is mobilized from the cavernous bodies and a ventral corporotomy is performed, a free transplant of the inner sheet of the foreskin is taken. The peculiarity is that the preserved urethral site is tubularized on a catheter of age diameter, the tubulated segment of the artifical urethra is fixed to the cavernous bodies and only after this the graft from the inner sheet of the foreskin is fixed from the distal meatus to the top of the head, and after 6 months from the first intervention, the prefabricated flap it is secreted with a bordering incision and tubularized on a catheter of age diameter.

The proposed method is illustrated in FIG. 1-fig. 9 where

in FIG. 1 and FIG. 2 shows the separation of the skin of the penis together with the adjacent fleshy membrane (superficial fascia) from the fascia of the tank;

In FIG. 3 shows the continuation of the circumcision section;

In FIG. 4 shows a rectangular defect from the distal edge of the urethral site to the top of the glans penis;

In FIG. 5 shows a free transplant fence of the inner leaf of the foreskin;

In FIG. 6 and 7 fixation of the tubularized segment and graft;

In FIG. Figures 8 and 9 show how a prefabricated flap is secreted with a bordering incision and tubularized on a catheter of age diameter.

Surgical intervention begins as standard for any hypospadias operation: a circumcision is made at a distance of 3-5 mm from the coronary sulcus along the dorsal surface, a native meatus and an urethral site on the penile shaft are lined with a bordering incision. The procedure is degloving (“scalping” of the penis) - the skin of the penis is separated along with the adjacent fleshy membrane (superficial fascia) from the fascia of the tank (deep fascia). FIG. 12

In the case when, when creating an artifact erection, we see a curvature of the penis of more than 30 degrees and dorsal plication of the corpora cavernosa leads to a pronounced shortening of the length of the penis, the urethral site intersects directly under the head of the penis by continuing the circumcision section. FIG. 3

Further, by well-known methods, the abandoned urethral site is mobilized from the cavernous bodies, a ventral corporotomy is performed (several transverse incisions are applied to the white membrane of the cavernous bodies), and if necessary, dorsal plication corporoplasty is performed according to Nesbit or Baskin. The head of the penis is revealed by a longitudinal section in the form of a “book”, the wings of the head are mobilized. During the manipulations, the saved urethral site is displaced proximally, and a rectangular defect forms from the distal edge of the urethral site to the top of the head of the penis along the ventral surface of the penis. FIG. four

A free transplant of the inner sheet of the foreskin is taken, sufficient to replace the defect along the ventral surface. FIG. 5

The preserved urethral site is tubularized on a catheter of age diameter. It is possible to apply a longitudinal relaxing incision to the urethral site. The tubularized segment of the artifactic urethra is fixed to the cavernous bodies and only after that the graft from the inner leaf of the foreskin is fixed from the distal meatus to the top of the head. FIG. 6, 7

The combination of technical techniques of Snodgrass and Bracka operations at this stage allows you to create a part of the artifical urethra with better properties than the cutaneous urethra and, as a result, reduce the length of the cutaneous urethra. Reduce the size of the taken transplant of the inner leaf of the foreskin, which allows you to use the remaining part of the foreskin for plastic surgery of the skin of the penis at the final 2nd stage of the operation.

After 6 months from the first intervention, the prefabricated flap is secreted with a bordering incision and tubularized on a catheter of age diameter. Usually the flap is wide enough and for its tubularization does not require a relaxing incision. FIG. 8, 9.

Due to the preservation of the urethral site and its use for urethroplasty with proximal forms of hypospadias, it is possible to reduce the length of the “skin” artifical urethra, thereby improving the properties of the formed urethra, eliminate the effects of stagnation of urine and ejaculate in the artifical urethra, and improve the quality of urination.

The proposed method for the surgical treatment of hypospadias has shown a good effect in practice.

Example No. 1

Patient K., 7 years old

With a congenital anomaly of the external genitalia is observed from birth. Sent to the urological department of the CSTO for surgical treatment.

The penis is curved ventrally; there is a deficiency of the skin of the penis along the ventral surface. The meatus is wide, opens in the penile-scrotum corner. The foreskin is split, in the form of a hood there is only on the dorsal surface, it is well expressed.

Diagnosis: hypospadias, penile-scrotal form

Bracka surgery was performed with the replacement of the urethral site with a free preputial graft.

A traction thread has been applied to the glans penis with a 6-0 proline. Applied: a fringing incision around the glans penis (along the dorsal and lateral surfaces), 5 mm indent from the coronary sulcus, bordering incision under the native meatus, 3 mm indent, and also incisions along the edge of the urethral site to the right and left. The skin of the penis is separated by a block with a superficial fascia from the fascia of the tank, the penis is “undressed”. A test with artificial erection by introducing a physiological solution of sodium chloride into the right cavernous body was carried out, a pronounced curvature of the penis within 90 degrees was noted. At the site of maximum curvature, the urethral site was intersected, the urethral site and underlying tissues along the ventral surface were completely excised to the white membrane of the cavernous bodies. A repeated test with artificial erection demonstrates the previous curvature of the penis, thus the imbalance of the cavernous bodies themselves was the cause of the curvature. On the ventral surface of the penis, 3 parallel incisions were made on the white membrane of the corpora cavernosa, an application was made for defects in the white membrane with a 1: 2000 epinephrine solution. A repeated test with artificial erection shows a residual curvature of the cavernous bodies within 30 degrees. The dorsal neurovascular bundle was mobilized, plicating sutures were put on the protein membrane of the cavernous bodies along the dorsal surface. On a test with artificial erection, cavernous bodies are straight. A graft of the inner leaf of the foreskin was taken. The glans penis is longitudinally dissected along the ventral surface in the form of a “book”. The preputial transplant is fixed along the ventral surface to the position of the urethral site from the top of the head to the native meatus with Vicryl 7-0. A silicone Foley catheter of 10 Fr. is installed in the bladder. Stitches for wounds. Ointment pressure bandage pilot. The catheter is removed on day 10, urination is free

After 9 months, the graft is well vascularized.

The 2nd stage of the operation. A traction thread has been applied to the glans penis with a 6-0 proline. Applied: bordering incision under the native meatus retreating 3 mm, as well as incisions along the edge of the urethral site on the right and left. Tubularization of the urethral site on a catheter 8 Fr. was performed using PDS 6-0 thread. The suture line on the articular urethra is additionally covered by the superficial fascia of the penis. Stitches on the wound. Aseptic ointment dressing. Catheter removed 12 days, free urination

Example No. 2

Patient B., 5 years old

With a congenital anomaly of the external genitalia is observed from birth. Sent to the urological department of the CSTO for surgical treatment. Previously also conducted orchiopexy from 2 sides regarding cryptorchidism

The penis is ventrally curved, immersed in the soft tissue of the scrotum. The scrotum is split and partially surrounds the base of the penis. The meatus is wide, opens on the scrotum. The foreskin is split, in the form of a hood there is only on the dorsal surface, it is well expressed.

Diagnosis: hypospadias, scrotal form. Member-scrotal transposition Bracka was performed in a modification with the replacement of the urethral site with a free preputial transplant.

A traction thread has been applied to the glans penis with a 6-0 proline. Applied: a fringing incision around the glans penis (along the dorsal and lateral surfaces), 5 mm indent from the coronary sulcus, bordering incision under the native meatus, 3 mm indent, and also incisions along the edge of the urethral site to the right and left. The skin of the penis is separated by a block with a superficial fascia from the fascia of the tank, the penis is “undressed”. A test with artificial erection by introducing a physiological solution of sodium chloride into the right cavernous body was carried out, a pronounced curvature of the penis was noted within 60 degrees. An intersection of the urethral site was carried out ventrally along the coronary sulcus, the urethral site was mobilized from the tunica albuginea. A repeated test with artificial erection demonstrates the curvature of the penis within 50 degrees, so the cause of the curvature was not only shortening and dysplasia of the urethral site, but to a greater extent the imbalance of the cavernous bodies themselves. On the ventral surface of the penis, 3 parallel incisions were made on the white membrane of the corpora cavernosa, an application was made for defects in the white membrane with a 1: 2000 epinephrine solution. On a repeated test with artificial erection, cavernous bodies are straight. Tubularization of the preserved urethral site was performed on a Nelaton 8 Shr catheter with PDS 7-0 thread. The neomeatus is fixed to the cavernous bodies at the border of the lower and middle 1/3 of the penis. A graft of the inner leaf of the foreskin was taken. The glans penis is longitudinally dissected along the ventral surface in the form of a “book”. The preputial graft is fixed along the ventral surface to the position of the urethral site from the top of the head to the neomeatus with Vicryl 7-0. Stitches for wounds. Ointment pressure bandage pilot. The catheter is removed on day 10, urination is free

After 7 months, the graft is well vascularized.

The 2nd stage of the operation. A traction thread has been applied to the glans penis with a 6-0 proline. Applied: bordering incision under the native meatus retreating 3 mm, as well as incisions along the edge of the urethral site on the right and left. Tubularization of the urethral site on a catheter 8 Fr. was performed using PDS 6-0 thread. The suture line on the articular urethra is additionally covered by the superficial fascia of the penis. Stitches on the wound. Aseptic ointment dressing. The catheter was removed on day 12, urination is free. "

Claims (1)

A method for the surgical treatment of proximal hypospadias, including a circumcision incision with the release of the native meatus and urethral site on the penile shaft, separating the skin of the penis together with the meaty membrane adjacent to it from the fascia of the Bucca, in the case when, when creating an artifact erection, the curvature of the penis is more than 30 ° and dorsal plication of the cavernous bodies will lead to a pronounced shortening of the length of the penis, the urethral area is crossed directly under the head of the penis the continuation of the circumcision section, then the left urethral site is mobilized from the corpora cavernosa and the ventral corporotomy is performed, a free transplant of the inner sheet of the foreskin is taken, characterized in that the stored urethral area is tubularized on a catheter of an age diameter, the tubular segment of the artifact urethra and the urethrosis are fixed to only after that the graft from the inner sheet of the foreskin is fixed from the distally displaced mea whisker to the top of head, and after 6 months from the first interference fringing prefabrikovanny flap is released and cut tubulyariziruetsya age on the catheter diameter.

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