RU2738557C1 - Surgical treatment method of hypospadias - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to urology. Urethral plate is excised, exposing cavernous bodies and straightening a penis. One or two flaps are cut out of the foliate penis of the patient. One or two cut out flaps are anchored to cavernous bodies to form bed. Patient's cheek mucous flap is cut out. Mucous membrane is anchored to pre-formed bed. After engraftment of the mucous flap, the urethra is formed by cutting out the edges of the mucous flap and suturing them into a tubular urethra. Penile flesh flap is used as a bed for a mucosa of the jaw intended for stitching in a tubular urethra in a method of surgical treatment of hypospadias.

EFFECT: method and application enable to significantly reduce the number of complications, improve social rehabilitation of the patients suffering from hypospadias, enhance their quality of life, enable to be sexually active and prevent the development of infertility.

15 cl, 3 ex, 8 dwg

Description

The invention relates to medicine, more specifically to the field of surgical urology in children and adults, and can be used to treat patients with hypospadias, in particular with severe (proximal) forms of hypospadias.

State of the art

Hypospadias is an anomaly in the development of the penis in which there is an abnormal position of the external opening of the urethra (meatus), including cases where the meatus is located not on the glans penis, but below - in the trunk or in the scrotum. In addition, hypospadias is often accompanied by a curvature of the penis.

The causes of this pathology are not fully understood, but it is known that hypospadias is a congenital disease that forms in the 1st trimester of pregnancy under the influence of various negative factors, such as genetic mutations, hormonal disorders and other exogenous and endogenous factors. Over the past 20 years, the incidence of hypospadias has increased to 1 in 150 newborns.

Treatment of hypospadias is possible only with surgical methods. In the absence of treatment of the stem and proximal forms of hypospadias, sexual activity and childbirth are impossible. Only full-scale reconstructive plastic surgery can resolve the physical and social problems of a patient with hypospadias.

At the present stage of medical development, the standard of surgical treatment for hypospadias is the creation of a natural appearance of the penis, without curvature, with minimal postoperative scars and with a meatus located at the apex of the glans penis. To achieve this result, it is necessary to assess the presence and degree of curvature of the penis and eliminate it, perform urethroplasty with the formation of meatus at the apex of the head, and also reconstruct the skin of the penis, giving the entire organ a physiological appearance. Inconsistency of the appearance of the penis with the natural one, for example, persistent curvature of the penis, abnormal location of the meatus, the presence of rough scars and deformed skin, can lead in adolescents and young men to the development of an inferiority complex, accompanied by fear of public display of genitals and intimacy.

In clinical practice, distal forms of hypospadias are distinguished (about 80-85% of the total number of cases), in which the meatus is located within or near the glans penis, and proximal forms of hypospadias (about 15-20% of the total number of cases), with which meatus is located at a distance from the glans penis, for example, in the lower part of the shaft of the penis, in the scrotum or perineum.

Surgical treatment of distal forms of hypospadias is quite standard and the risk of complications, according to literature data, ranges from 2 to 10%. [Warren T. Snodgrass, "Algorithm for Comprehensive Approach to Hypospadias", Journal of Urology, 2010, 82, 2885-2892; Peter Cuckow et al, "Long-term outcomes of pediatric hypospadias and surgical intervention", Pediatric Health, Medicine and Therapeutics, 2012, 3, 69-77; Adam E. Perlmutter, "Impact of patient age on distal hypospadias repair: a surgical perspective", Urology, 2006, 68 (3), 648-651; S. Vallasciani, “Observational retrospective study on acquired megalourethra after primary proximal hypospadias repair and its recurrence after tapering,” Journal of Pediatric Urology, 2013, 9, 364-367; Anne-Françoise Spinoit, "Hypospadias Repair at a Tertiary Care Center: Long-Term Followup is Mandatory to Determine the Real Complication Rate", J. Urol., 2013; 189 (6), 2276-81].

At the same time, surgical treatment of proximal forms of hypospadias is particularly difficult, due to the need to create a long urethra and, as a rule, to eliminate the curvature of the penis. Treatment of proximal forms has a higher risk of complications, constituting, according to literature data, from 30 to 68% [Stanasel I. et al. Complications following staged hypospadias repair using transposed preputial skin flaps, J. Urol., 2015; 194,512-516; McNamara E. R. et al. “Management of proximal hypospadias with 2-stage repair: 20-year experience”, J. Urol., 2015, 194, 1080-1085; Castagnetti M et al. “Primary severe hypospadias: comparison of reoperation rates and parental perception of urinary symptoms and cosmetic outcomes among 4 repairs”, J. Urol., 2013, 189, 1508-1513]. The most common postoperative complications are defects (fistulas) of the urethra, stenosis, urethral diverticula, as well as cicatricial deformities of the skin [Vallasciani S. et al, “Observational retrospective study on acquired megalourethra after primary proximal hypospadias repair and its recurrence after tapering”, J. Pediatr. Urol., 2013, 9, 364-367; Pippi Salle JL et al. “Proximal hypospadias: a persistent challenge. Single institution outcome analysis of three surgical techniques over a 10-year period ”, J. Pediatr. Urol., 2016,12 (1), 28.e1-7; Snodgrass W, Bush N. “Tubularized incised plate proximal hypospadias repair: continued evolution and extended applications”, J. Pediatr. Urol., 2011, 7, 2-9]. Correction of repeated proximal forms of hypospadias after unsuccessful urethroplasty is one of the most difficult problems due to the pronounced deficiency of local plastic material and cicatricial changes in the skin.

The existing methods of surgical treatment of hypospadias can be divided into one-stage and two-stage.

One-stage methods involve the mobilization of a skin flap on the supply vessels, its movement and the simultaneous formation of an artifactual urethra (see, for example, Duckett JW Jr., "Transverse preputial island flap technique for repair of severe hypospadias", Urol. Clin. North Am., 1980, 7 (2), 423-430). The disadvantage of one-stage methods is the risk of local ischemia, which can lead to the formation of fistulas or stenosis of the urethra. In addition, a large supply of local tissue is required to create the urethra. Urethroplasty performed by this method unsuccessfully in patients with proximal forms of hypospadias leads to a deficiency of local tissues and scarring changes in the skin of the penis, which makes it impossible to use subsequent one-stage operations.

Two-stage methods of correcting proximal forms of hypospadias differ in the use of various types of tissues for urethroplasty - local (skin of the foreskin) or heterotopic (mucous membrane of the cheeks or lips). This method gained popularity after the publication by the surgeon A. Bracka in 1995 of information on the use of this technique in 600 patients with a minimal complication rate (6%) [Bracka A., "Hypospadias repair: the two-stage alternative", Br. J. Urol. 1995, 76, suppl. 3, 31-41]. Using the Bracka method allows you to create a urethra from the buccal mucosa - a material similar in histological structure to the native urethra, and at the same time the problem of tissue deficiency is solved, i.e. it becomes possible to receive a long-term graft.

In the known method described by Bracka, in a first step, an incision is made along the midline of the penis and the glans of the penis is split. After excision of the chord and straightening of the penis, a flap of mucous membrane of the required size is cut out from the lateral surface of the cheek. The flap is thoroughly cleaned from the underlying tissue from the inner surface, so that the flap gains good elasticity. Then the flap is fixed on the defect of the volar surface formed after straightening with the formation of the urethral plate. At the second stage, which is performed 6 months after the final engraftment of the mucous flap, the artifical urethra is formed by tubularization of the created urethral plate, the meatus is formed, and the head plastic is performed. The artifical urethra is covered with local tissues, and skin grafting is performed.

Bracka suggested using this method in proximal forms of hypospadias, as well as in patients who have undergone a number of unsuccessful operations, when the volar surface is represented by scars and there is a deficiency of local tissues.

In the literature, one can find statements that the use of free grafts and two-stage surgical treatment significantly alleviate the problem of local tissue deficiency and reduce the risk of complications [Bracka A., "Hypospadias repair: the two-stage alternative", Br. J. Urol. 1995, 76, suppl. 3, 31-41; Hensle T.W. et al "Buccal mucosa grafts for hypospadias surgery: long-term results", J. Urol., 2002, 168 (4 Pt 2), 1734-1736; Snodgrass W, Elmore J. “Initial experience with staged buccal graft (Bracka) hypospadias reoperations”, J. Urol., 2004, 172, 1720–1724].

However, there are complications with the Bracka method. According to a number of authors, as a result of the use of a flap of the buccal mucosa, the incidence of complications reached 66% [Snow B.W., Cartwright P.C. "The yoke hypospadias repair", J. Pediatr. Surg., 1994, 29, 557-560]. Information was also given on the occurrence of complications in 34% of cases after using a flap of the buccal mucosa with a follow-up period of four years [Hensle T.W. et al, "Buccal mucosa grafts for hypospadias surgery: long-term results", J. Urol., 2002, 168 (4 Pt 2), 1734-1736]. W. Snodgrass noted the occurrence of complications in 38% of cases, mainly in the form of urethral fistula formation [Snodgrass W, Elmore J. "Initial experience with staged buccal graft (Bracka) hypospadias reoperations", J. Urol., 2004, 172, 1720-1724 ]. Emilie Johnson in a 2014 publication noted the development of complications in 60% of cases in the form of fistulas and strictures [Emilie K Johnson et al, “Use of buccal mucosa grafts for urethral reconstruction in children: a retrospective cohort study”, BMC Urology, 2014, 14 : 46]. One of the main reasons for the development of complications when using a flap of the buccal mucosa is flap hyperplasia or its fibrous degeneration during engraftment, which subsequently led to the formation of a thickened rigid plate. The use of a thickened rigid flap is associated with significant difficulties in the formation of a tubular urethra, which causes the development of stenosis and fistulas of the urethra.

So, in the histological analysis of the results of the use of the buccal mucosa, surgeons Bruno Leslie, Armando J. Lorenzo noted that a third of patients developed fibrosis / flap compaction, and after the second stage complications occurred in 82% of these patients, while in patients with no of these adverse changes, the complication rate was 19% [Bruno Leslie et al, “Critical Outcome Analysis of Staged Buccal Mucosa Graft Urethroplasty for Prior Failed Hypospadias Repair in Children,” Yearbook of Urology 2011, 2011, 232-233]. When the flap successfully engrafted, the authors noted the close structure of the graft to the native urethra. Hyperplasia and fibrous transformation of the flap are indicated by the authors as the main cause leading to the formation of stenosis and fistulas of the urethra.

Summarizing the information available in the prior art, it should be stated that the use of two-stage urethroplasty according to Bracka using a free flap of the buccal mucosa is a promising technique for solving the problem of local tissue deficiency and achieving good functional and cosmetic results in surgical treatment of hypospadias, however, the known techniques of this operation have significant disadvantages, as indicated by the high frequency of complications.

There is a need for an improved method of surgical treatment of hypospadias, especially its proximal forms, which would reduce the likelihood of complications both in the short and medium term and in the long term, and thus obtain a more reliable and stable clinical effect than in the known ways.

Disclosure of invention

The present invention relates to a new method for the surgical treatment of hypospadias, including the following operations:

1) the urethral plate and, if necessary, the chord deforming the penis are excised from the patient, exposing the corpora cavernosa and straightening the penis;

2) one or more flaps are cut out from the dartos of the patient's penis;

3) one or more cut out flaps are sutured to the corpora cavernosa, forming a bed;

4) cut out one or more flaps from the patient's cheek mucosa;

5) one or more mucous cheek flaps are sutured to a pre-formed bed;

6) after engraftment of one or more mucous flaps, the urethra is formed by cutting out the edges of one or more mucous flaps and stitching them into the tubular urethra.

The invention also relates to the use of a penile meatus flap as a bed for one or more buccal mucous flaps to be sutured into a tubular urethra in a method for the surgical treatment of hypospadias.

The inventors have surprisingly found that the method according to the invention is significantly more reliable and highly efficient than the prior art. The buccal mucosa, fixed to the fleshy flaps, is well supplied with blood and engrafts much better than described in the literature. At the same time, the flap remains elastic, which greatly simplifies the formation of the urethra from the mucosal flap and minimizes the number of complications in urethroplasty.

Thus, the method provides a significant reduction in the number of complications, can significantly improve the social rehabilitation of patients suffering from hypospadias, improves their quality of life, opens up the opportunity for a normal sexual life and prevents the development of infertility.

This technical result is achieved due to the fact that the authors refused to lay the mucous flap directly on the corpora cavernosa after excision of the urethral plate and chord, deforming the penis. Instead, in the method according to the invention, the mucous flap is laid and sutured onto a bed formed from the dartos of the penis. Without wishing to be bound by any theory, the authors believe that this makes it possible to improve the blood supply to the flap, to achieve a higher quality and elasticity of the engrafted mucosal flap, which is the prevention of such complications as the development of fistulas and urethral defects during subsequent urethroplasty from this flap.

Brief Description of Drawings

FIG. 1 is a schematic representation of the penis of a patient suffering from hypospadias and curvature of the penis before surgery.

FIG. 2 is a schematic view illustrating excision of the chord deforming the penis and straightening the penis.

FIG. 3 is a schematic diagram illustrating the cutting of dartos flaps from the lateral surfaces of the penis.

FIG. 4 is a schematic diagram illustrating the suturing of cut-out flaps to the corpora cavernosa to form a mucosal flap bed.

FIG. 5 is a schematic diagram illustrating the cutting of a flap from the lateral surface of the buccal mucosa with a transition to the lip.

FIG. 6 is a schematic diagram illustrating the suturing of a mucosal flap to a formed bed.

FIG. 7 is a photograph showing the altered, rigid state of the mucosa 6 months after surgery in the manner described in the literature.

FIG. 8 is a photograph showing the unchanged elastic state of the mucosa 6 months after surgery in accordance with the method of the invention.

Implementation of the invention

It should be understood that all documents cited in this description are fully incorporated into the present description by reference.

In the present invention, "hypospadias" means any anatomical anomaly of the penis in which there is an abnormal position of the external opening of the urethra (meatus), including mild and severe and / or distal and proximal forms of hypospadias, including those accompanied by curvature of the penis. However, the most pronounced technical result according to the invention is achieved in the case of surgical treatment of proximal forms of hypospadias.

Since hypospadias is a congenital disorder, surgical treatment of hypospadias according to the present invention is preferably performed in children, however, it is important to understand that the application of the method of the present invention is not limited only to the field of pediatric urology, and the method of the invention can also be used for the treatment of adolescents, and adult patients.

The method of surgical treatment of hypospadias according to the present invention includes the following operations:

1) the urethral plate and, if necessary, the chord deforming the penis are excised from the patient, exposing the corpora cavernosa and straightening the penis;

2) one or more flaps are cut out from the dartos of the patient's penis;

3) one or more cut out flaps are sutured to the corpora cavernosa, forming a bed;

4) cut out one or more flaps from the patient's cheek mucosa;

5) one or more mucous cheek flaps are sutured to a pre-formed bed;

6) after engraftment of one or more mucous flaps of the cheek, the urethra is formed by cutting out the edges of one or more mucous flaps and stitching them into the tubular urethra.

The operations of excision of the urethral plate, as well as, if necessary, excision of the chord deforming the penis, and straightening of the penis can be carried out according to known techniques described in the literature. For example, in this connection, you can refer to the documents cited in the "Background" section. In one embodiment, the urethral repair may be excised with parallel incisions along the underside of the penis.

As a result of excision of the urethral plate and chord, which deforms the penis, the penis is straightened and the cavernous bodies are exposed.

Then one or more flaps are cut out from the dartos of the penis. In a preferred, but non-limiting, embodiment, the flaps are cut from the lateral surfaces of the penis. In a particularly preferred embodiment of the invention, two symmetrical overlapping flaps are cut from the lateral surfaces of the penis.

Although the shape of the flaps cut out is not limited in any way and can be chosen by the surgeon for reasons of convenience and practicality, in a preferred embodiment, the flaps are approximately rectangular in shape.

The resulting one or more flaps are then sutured (preferably along the midline) to the corpora cavernosa and, if necessary, are sutured together to form a bed.

Then one or more flaps are cut out from the mucous tissue. In a preferred (but not limiting) embodiment, the mucous tissue is buccal mucosa, such as buccal mucosa with a transition to the lip. The mucosal defect is sutured in accordance with known methods.

The cut out one or more mucosal flaps are preferably freed from the underlying adipose tissue according to known techniques so that they are thin translucent films.

One or more mucous flaps are sutured to a preformed bed.

After engraftment of one or more mucous flaps, the urethra is formed by cutting out the edges of one or more mucous flaps and stitching them into the tubular urethra. The stage of forming the urethra from mucous flaps is carried out by known methods described in the prior art. For example, in this connection, you can refer to the documents cited in the "Background" section. Briefly, it can be noted that this stage includes the mobilization of the edges of one or more mucous flaps, suturing into a tube, covering the urethra with a well-vascularized tissue (as a rule, the dartos is used from some part of the penis) and suturing the skin over the resulting structure.

In a preferred embodiment, the stage of forming the urethra from mucous flaps is carried out several months after suturing the mucosal flaps to the bed formed on the penis. For example, the stage of formation of the urethra can be carried out 4-8 months after suturing the mucosal flaps to the bed formed on the penis, in the most preferred embodiment after 6 months.

Examples of

General methodology

Surgical intervention was performed under general anesthesia. The position of the patient is on the back (Fig. 1). A ligature was applied to the glans penis.

The operation began with parallel incisions along the lower surface of the penis, while the urethral plate was excised.

The chord deforming the penis was excised, exposing the corpora cavernosa, and the penis was straightened (Fig. 2).

Rectangular flaps were cut from the lateral surfaces of the penis from the dartos (Fig. 3). The flaps were sutured along the midline to the corpora cavernosa, forming a bed for the mucous flap (Fig. 4).

A flap was cut out from the lateral surface of the buccal mucosa with a transition to the lip (Fig. 5). The defect of the buccal mucosa was sutured.

The mucous flap was freed from the underlying adipose tissue. The flap was sutured with separate interrupted sutures to the previously formed bed (Fig. 6).

The operation was completed with the imposition of aseptic compression bandage on the postoperative wound and the shaft of the penis, which has a hemostatic effect in the early postoperative period.

After engraftment of the mucous flap, the urethra was formed by cutting out the edges of one or several mucous flaps and stitching them into the tubular urethra, followed by covering the formed urethra with the dartos and stitching the skin over the resulting structure.

Clinical example 1. Application in children.

Patient Daniel M. 3 years old was admitted to the hospital with a diagnosis of hypospadias, scrotal form. It is known from the anamnesis that the disease was diagnosed at birth.

On examination: the external opening of the urethra is located in the scrotal region. The penis is curved downward. The foreskin in the form of a hood from the back of the penis (dorsal surface). The scrotum is split along the midline.

The patient was operated on according to the proposed method, under endotracheal anesthesia in the supine position.

The postoperative period was uneventful, without complications. The bandage and urethral catheter were removed on the 7th day.

At the control examination after 6 months. the penis is not curved, the cheek mucosa is soft, elastic, without signs of inflammation. The result was recognized as good. The second stage of the operation was performed - the formation of the urethra by mobilizing the mucous flap and stitching it into the tubular urethra.

After 14 days, the urethral stent and cystostomy drainage were removed. The child urinates freely, painlessly, with a wide stream from the glans penis. The result of the operation was regarded as good and remained the same in the long-term postoperative period, including after 1 year, 3 years and 6 years. The patient experienced independent urination with a wide stream, without straining, from the urethral opening located at the apex of the penis, there were no rough postoperative scars on the penis, the penis has a natural appearance.

Clinical example 2. Use in adults.

Patient Ilya Z. 23 years old was admitted to the clinic with a diagnosis of hypospadias, scrotal form. Condition after repeated surgical interventions. It is known from the anamnesis that the disease was diagnosed at birth. Orthoplasty (straightening) of the penis was performed at the age of 3 years. Then, at the age of 5 years - plastic surgery of the urethra, in the postoperative period, there was a divergence of the sutures of the trunk of the urethra. Later, at the age of 5.5 years, repeated plastic surgery of the urethra, after the operation, a fistula of the urethra was recorded. At the age of 7, 9 years - attempts to plasty the fistula of the urethra, after operations, the fistula recurred.

Upon admission to the clinic for examination: the external opening of the urethra is located in the area of the coronary groove, the penis is curved ventrally. The foreskin is absent. There are multiple scars along the ventral surface. There is a fistula in the middle of the penis. Urines at a reduced rate, with straining 5-6 ml / sec.

The patient underwent surgery in accordance with the method according to the invention, under endotracheal anesthesia in the supine position.

The cicatricial urethra was excised from the coronary sulcus to the scrotal region, an external urethral opening was formed in the scrotal region, and the penis was straightened by excision of scars and fibrous tissue (the remains of the chord).

After that, fleshy flaps were cut from the lateral surfaces of the penis. The flaps were placed on the corpora cavernosa, sutured along the midline with 5/0 vicryl interrupted sutures.

A flap was cut from the right cheek with a transition to the lip about 6 cm long and 2 cm wide, the flap was freed from the underlying fatty tissue. The cheek wound was closed with continuous Vicryl 4/0 sutures.

The mucosal flap was placed on the ventral surface of the penis over the fleshy flap and sutured with 5/0 Vicryl interrupted sutures. A compressive compression bandage was applied, a 16 Cn urethral catheter was placed. The postoperative period was uneventful, without complications. The bandage and urethral catheter were removed on day 7.

At the control examination after 6 months. the penis is not curved, the cheek mucosa is soft, elastic, without signs of inflammation. The result was recognized as good. The second stage of the operation was performed - the formation of the urethra by mobilizing the mucous flap and stitching it into the tubular urethra.

After 14 days, the urethral stent and cystostomy drainage were removed. The patient urinates freely, painlessly, with a wide stream from the glans penis. Urination rate 10-12 ml / sec. The result of the operation was regarded as good and remained the same in the long-term postoperative period, including after 1 year, 3 years and 6 years. The patient experienced independent urination with a wide stream, without straining, from the opening of the urethra located at the apex of the penis, there were no rough postoperative scars on the penis, the penis has a natural appearance.

Clinical example 3. Application of the method according to the invention after the unsuccessful application of the method known from the prior art.

Patient I. 12 years old was admitted to the clinic with a diagnosis of "scrotal hypospadias". After an additional examination and preoperative preparation, the operation was performed - orthoplasty of the penis (straightening), stage 1 of the Bracka operation using the buccal mucosa:

The urethral plate and fibrous chord were excised by a midline incision along the lower surface of the penis. In this case, the corpora cavernosa were exposed, the penis was straightened. A 4x1.5 cm flap was cut out of the left cheek mucosa, the flap was processed and placed on the lower surface of the penis, fixed to the corpora cavernosa with interrupted 5/0 vicryl sutures.

6 months after the operation, the flap was a rigid, 1 cm thick, bright pink plate. The formation of the urethra by tubularization (folding into a tube and suturing) was not possible. In this regard, the mucous flap was excised and a similar flap cut from the mucous membrane of the right cheek was sewn.

After 6 months with urethroplasty, difficulties were observed associated with difficulties in mobilizing the edges of a thickened, rigid flap. Despite this, the urethroplasty was completed. The postoperative period was complicated by the divergence of the urethral sutures in the middle of the penis.

Later, after a year, the entire created urethra was excised, after the formation of a bed from the dartos of the lateral surface of the penis, a flap from the buccal mucosa was cut and sewn.

After 6 months, the second stage was performed - plastic surgery of the urethra. No difficulties were observed, the mucosal flap was soft, elastic, easily rolled into a tube and sutured. After removing the drains, the patient freely urinated from the external urethral opening located on the glans penis. Positive results were also observed in the long term - after 6, 12, 18 months.

Results statistics

For a reliable study of the technical result according to the invention, the authors have carried out many surgical operations to treat various forms of proximal hypospadias. 8 negative results were recorded, in which in the absence of a special support under the mucosal flap, rigid, altered flaps were observed (for example, see Fig. 7).

On the other hand, when using the claimed method, more than 200 positive results were obtained, in which the mucosal flaps remained soft and elastic (for example, see Fig. 8).

Thus, clinical trials have shown that the claimed invention actually provides the claimed technical result, which consists in significantly better engraftment of mucosal flaps. At the same time, the flap remains elastic, which greatly simplifies the formation of the urethra and minimizes the number of complications in urethroplasty, improves social rehabilitation of patients, improves their quality of life, opens up the opportunity for a normal sexual life and prevents the development of infertility.

Claims (21)

1. A method of surgical treatment of hypospadias, including the following operations: 1) the urethral plate is excised from the patient, exposing the corpora cavernosa and straightening the penis; 2) one or two flaps are cut out from the dartos of the patient's penis; 3) one or two cut out flaps are sutured to the corpora cavernosa, forming a bed; 4) cut out a flap from the patient's cheek mucosa; 5) the mucous flap is sutured to a pre-formed bed; 6) after engraftment of the mucous flap, the urethra is formed by cutting out the edges of the mucous flap and stitching them into the tubular urethra. 2. The method according to claim 1, wherein in step 1, the chord deforming the penis is further excised. 3. The method of claim 1 or 2, wherein the hypospadias is a proximal form of hypospadias, such as a scrotal form of hypospadias. 4. A method according to any one of claims. 1-3, in which two symmetrical opposite flaps are cut out from the dartos of the lateral surfaces of the penis. 5. The method according to any one of claims. 1-4, in which one or two flaps cut out from the dartos of the penis are rectangular. 6. The method according to any one of claims. 1-5, in which the buccal mucosa is the cheek mucosa with a transition to the lip. 7. A method according to any one of claims. 1-6, in which the cut mucous flap is freed from the underlying fatty tissue so that it is a thin translucent film. 8. The method according to PP. 1-7, in which the urethra is formed by cutting out the edges of a mucosal flap, suturing them into a tubular urethra, covering the urethra with well vascularized tissue such as the dartos from the penis, and suturing the skin over the resulting structure. 9. A method according to any one of claims. 1-8, in which the stage of formation of the urethra is carried out 4-8 months after suturing the mucosal flap to the bed formed on the penis. 10. The method according to any one of claims. 1-9, in which the stage of formation of the urethra is carried out 6 months after suturing the mucosal flap to the bed formed on the penis. 11. The method according to any one of claims. 1-10, in which the patient is a child, adolescent, or adult. 12. The use of a flap of the dartos of the penis as a bed for a mucous flap of the cheek, intended for suturing into the tubular urethra, in the method of surgical treatment of hypospadias. 13. Use according to claim 12, wherein the hypospadias is a proximal form of hypospadias, such as a scrotal form of hypospadias. 14. Application according to PP. 12, 13, in which the flap cut out from the meatus of the penis has a rectangular shape. 15. Use according to any one of claims 12 to 14, wherein the buccal mucosa is a buccal mucosa with a transition to the lip.

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