RU2836015C1 - Method for penile curvature correction by means of free flap of albuginea of testis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to surgical urology. Circular incision of the penis skin is performed. Penis is skeletonized to the base; in the place of fibrous induration, the tunica albuginea is exposed and excised within the healthy tissue. Then the cavernous body tunica albuginea defect is replaced with a flap. Free flap is separated from the albuginea of the testis; the defect of the albuginea of the penis is closed by fixing the obtained free flap of the albuginea of the testis to the albuginea of the cavernous bodies with interrupted sutures. Blanket suture is applied on the defect of the tunica albuginea of the middle one-third of the penis body within the fibrous plaque resection area.

EFFECT: method enables reducing the risk of infection, resorption and fragmentation, in the form of fibrosis zones, and also enables creating functional comfort during erection and detumescence.

1 cl, 3 dwg, 3 ex

Description

Field of technology to which the invention relates

The invention relates to the field of medicine, in particular to a method for correcting penile curvature using a free flap of the tunica albuginea of the testicle, and can be used in specialized urological departments.

State of the art

A method is known for correcting the scrotal and shaft forms of hypospadias, which includes straightening the penis with excision of the altered skin and chord, forming an artificial urethral tube from the skin of the penis, anastomosing the proximal part of the formed urethra with the hypospadic meatus, fixing the distal part of the urethra at the apex of the head, suturing the skin defect, while making a bordering incision around the head of the penis along the edge of the coronal groove, continuing the incision along the ventral surface of the penis to the hylospadic meatus, after which the skin is mobilized around the shaft of the penis to the shaft-scrotal angle, then an artificial urethral tube is formed from one edge of the mobilized skin, equal in length to the urethral deficiency, placing sutures on the side of the cavernous bodies, and suturing the other edge of the mobilized skin along the base of the artificial urethra above it. A method according to claim 1 is known, wherein, in the case of a urethral deficit exceeding the length of the longitudinal edge of the mobilized skin, the outer leaf of the prepuce along the dorsal surface of the penis is used to increase its length (see patent RU No. 2199955, IPC A61B 17/00, published 10.03.2003, bulletin No. 7).

The disadvantage of this method is the insufficient improvement of the blood supply to the artificial urethra.

A method of surgical treatment of complicated forms of trunk hypospadias is known, including replacement of the missing part of the urethra with a tube formed from two rectangular flaps of skin cut on the ventral surface of the penis and on the anterior surface of the scrotum and subsequent isolation of the penis from the scrotum after 2-3 months, wherein first two parallel incisions are made on the ventral surface of the penis from the coronary groove to the level of the external opening of the urethra, below the meatus the incisions are connected, forming a rectangular flap, then, stepping back from the penoscrotal angle at a distance equal to the length of the penis from the external opening of the urethra to the scrotum, a rectangular flap is formed on the anterior surface of the scrotum, the size corresponding to that on the penis, then the parallel incisions on the penis and scrotum are connected and the resulting rectangular flap is excised in the area of the penoscrotal angle, then urethroplasty by suturing the apices and lateral surfaces of the flaps of the ventral surface of the penis and the anterior surface of the scrotum, then the outer edges of the skin wounds of the penis and scrotum are sutured, after 2-3 months the penis is isolated from the scrotum (patent RU No. 2284767, IPC A61B 17/00, A61B 17/322, published 10.10.2006, bulletin No. 28).

The disadvantage of this method is insufficient blood circulation in the detached scrotal skin flap and insufficient cosmetic effect.

A method for forming a skin flap during urethral plastic surgery is known, which includes marking the skin flap, isolating the skin flap, creating a neourethra by forming a tubular flap, suturing the skin wound, while in order to improve the results of surgical treatment of this disease, a longitudinal ribbon-like continuous flap is marked on the dorsal surface of the penis, the width of which corresponds to the length of the circumference of the neourethra, having two layers, one of which is a strip of rectangular skin on the dorsal surface of the penis from the head to the pubis, with parallel edges, symmetrically diverging in the middle third by 2-3 mm; the second layer, formed by the subcutaneous base of the flap, is separated from the cavernous bodies in the form of a bridge-shaped strip, starting from the base of the head from the dorsal surface and ending at the base of the penis at the pubis, without cutting off the ends of the flap from the bases, the width of the subcutaneous fascia of the mobilized flaps exceeds the width of the skin part by 0.5 cm; in the area of the bases of the dorsal flap, the subcutaneous part is trapezoidally expanded by 1/5 of the width of the skin strip; the dorsal separated flap of skin with the subcutaneous base is sutured on a catheter in the form of a tube with interrupted absorbable sutures to create a neourethra; in the subcutaneous parts of both bases of the dorsal flap, two holes of the same diameter are formed in the center of the subcutaneous part using a blunt method, corresponding to the size of the head of the penis; to move the tubular graft to the volar surface, the glans penis is pulled sequentially, first into the opening closest to it, then into the second opening located at the base of the penis, while the formed tubular graft is turned with a line of sutures to the cavernous bodies, the distal end of which, adjacent to the glans, is moved proximally, anastomosed with the opening of the hypospadic urethra, and the proximal end is placed in the groove between the "wings" of the glans penis and a meatus is formed from it so that the tubular graft is turned 180 ° and turned with a line of sutures to the cavernous bodies, and at the same time moves from the dorsal surface to the volar, the suture line of the anastomosis of the tubular graft is closed with a trapezoid volar flap on a wide base, its free part is shifted to the glans and sutured with the skin protrusion of the tubular graft; to close the wound, a ventral flap is formed on the scrotum, the skin incisions are finished in an angular manner, directing them laterally, at an angle of 80-90°, as a result of the incisions, the formed lateral island flaps of skin are shifted on vascular connections towards the back of the penis and sutured together, the excess part of the subcutaneous fascia is placed and fixed with sutures under the separated wings of the glans penis, on the lateral surfaces of the scrotum at the base of the flap, triangular skin areas are formed, cut off at the base, which lengthens and straightens the suture line (see patent RU No. 2467707, IPC A61B 17/00, published 27.11.2012, bulletin No. 33).

The disadvantage of this method is the insufficient cosmetic effect and insufficient conditions for improving wound healing.

The closest in technical essence and achieved positive effect and accepted by the authors as a prototype is the method of correction of scrotal and trunk forms of hypospadias according to Duplay, which consists of two stages. At the first stage, after excision of the fibrous chord, a skin reserve is created on the ventral surface of the penis. For this, two parallel oblique skin incisions are made at an angle of 45 degrees in the middle third of the penis shaft on both sides of the longitudinal incision. The operation of the first stage ends with suturing the wound according to the principle of counter flaps according to Limberg. At the second stage, after 6 months, a U-shaped incision is made on the ventral surface of the penis, bending around the meatus along the proximal edge. The edges of the flap are mobilized. The flap is sutured into a tube. The lateral edges of the wound are sutured with a continuous furrier's suture. The operation ends with drainage of the bladder (Lopatkin N.A., Pugachev A.G. Pediatric Urology, Manual, Moscow: Medicine, 1986, 234-237).

The disadvantages of this method include the fact that it is a two-stage method, that the artificial urethra is formed from the cicatricially altered skin of the ventral surface of the penis, formed after the first stage of treatment, while the blood supply to the artificial urethra is carried out only due to perforating vessels from the cavernous tissue, which have grown into the skin of the ventral surface of the penis by the second stage of treatment, due to insufficient blood supply, the urethra lags behind the cavernous bodies in growth, which can lead to secondary deformation of the penis, short urethra syndrome, and also the fact that the second stage of treatment should be performed at a late age, when patients reach 12-13 years after the formation of the final dimensions of the penis, the suture line of the artificial urethra is located outward, in close proximity to the sutures of the skin, which contributes to the formation of urethral fistulas.

Disclosure of invention

The objective of the proposed invention is to develop a method for correcting penile curvature using a free flap of the tunica albuginea of the testicle, which has the ability to close large defects of the tunica albuginea of the cavernous bodies of the penis, when performing flap corporoplasty, using a free flap (graft) of the tunica albuginea of the testicle.

The technical result that can be achieved with the help of the proposed invention is reduced to the replacement during surgical treatment of the protein coat of the cavernous bodies, in case of large defects, with a free flap of the protein coat (graft) of the testicle, reducing the risk of infection, resorption and fragmentation, in the form of fibrosis zones.

The technical result is achieved using a method for correcting the curvature of the penis using a free flap of the tunica albuginea of the testicle, including a circular incision of the skin of the penis, whereby the penis is then skeletonized to the base, in the place of greater curvature of the penis in the place of fibrous induration of its tunica albuginea, the latter is opened and excised within the healthy tissue, then the defect of the tunica albuginea of the cavernous bodies is replaced by isolating the tissue of the tunica albuginea of the testicle and forming a free flap, which is then fixed to the tunica albuginea of the cavernous bodies with interrupted sutures with ligatures inward.

The essence of the method of correcting penile curvature using a free flap of the tunica albuginea of the testicle is as follows.

At the first stage, a circular incision is made in the skin of the penis, then the penis is skeletonized to the base. In the place of fibrous induration of the tunica albuginea of the penis, in the place of greater curvature of the penis, the latter is opened. Then the fibrous tissue, plaque, is excised within the healthy tissue. The defect of the tunica albuginea of the cavernous bodies is replaced by isolating the tissue of the tunica albuginea of the testicle and forming a free flap (graft). The free flap of the tunica albuginea of the testicle is fixed to the tunica albuginea of the cavernous bodies with interrupted sutures, ligatures inward. The use of a well-perfused flap reduces the risk of infection, resorption and fragmentation in the form of fibrosis zones. The property of the movable flap to stretch and contract allows for functional comfort during erection and detumescence.

Thus, the method of correcting penile curvature using a free flap of the tunica albuginea of the testicle is satisfactory and can be recommended for use.

Brief description of drawings and other materials

Fig. 1 shows a method for correcting penile curvature using a free flap of the tunica albuginea of the testicle, stages of surgical treatment, Fig. 1.

In Fig. 2, the same, fixed flap, photo 1.

In Fig. 3, the same, postoperative result, photo 2.

Implementation of the invention

Clinical examples of the use of the method of correcting penile curvature using a free flap of the tunica albuginea of the testicle.

Example 1. Patient M., born in 1968, 53 years old

I went to see a urologist-andrologist

Complaints - curvature of the penis to the left, impossibility of sexual intercourse. These complaints have been noted for the past 4 years. During examination by a urologist-andrologist, a dense, painless, immovable formation in the projection of the cavernous body on the left, up to 1.0 × 1.0 cm in size, was palpated. An ultrasound Doppler examination of the vessels of the penis with an intracavernous injection (the drug "Caverject") was performed - vascular blood flow is not impaired. Fibroplastic induration of the protein membrane of the cavernous body on the left was detected, measuring about 1.5 × 1.5 cm.

Surgical treatment. Flap corporoplasty of the penis was performed - excision of the fibrous plaque of the tunica albuginea of the penis with replacement of the defect with an autograft (tunica vaginalis testis). Method of surgery: With the patient lying on his back, under general anesthesia, in the area of the coronary groove of the penis, the tunica albuginea was opened by a circular incision of the skin down to the tunica albuginea. The penis was scalped to the base. Artificial erection was modulated, 1 ml of papaverine solution was injected intracavernously. During revision, in the projection of the third of the penis, in the projection of the cavernous body on the left, a compaction of the tunica albuginea was visualized - a fibrous plaque, round in shape, measuring 1.5 × 1.5 cm, causing deformation of the penis. A blunt and sharp method was used to resect the fibrous plaque of the tunica albuginea of the penis within healthy tissues (the plaque is presented as fibrous density tissue), the cavernous body is exposed. Hemostasis control. Due to the large size of the defect in the tunica albuginea of the penis, a decision was made to use an autograft from the testicular tunica. A 3-cm long skin incision was made in the right scrotal chamber, the tunica vaginalis of the right testicle was exposed by blunt and sharp means. It was resected. Upon revision, the tunica vaginalis was unchanged, the appendage was of normal color, the testicle was of normal size and consistency. Partial resection of the tunica vaginalis was performed. 1 oval-shaped area measuring 1.5 × 1.5 cm was obtained. Hemostasis control, layer-by-layer suturing of the membranes of the right scrotal chamber. Using the obtained autotransplant (1 section of the vaginal membrane of the right testicle), a closure of the defect of the protein membrane of the third part of the penis in the area of resection of the fibrous plaque was performed using a twisted suture with reinforcement in 2 layers. Hemostasis control. Layer-by-layer suturing of the surgical wound to the rubber graduate. Aseptic, compression bandage.

After discharge, the patient received conservative treatment - PDE-5 inhibitors (Tadalafil), the enzyme proteolytic drug "Longidaza". Subsequently, after 1 month, the patient underwent a course of LOD-therapy.

Example 2. Patient K., born in 1974, 48 years old

I went to see a urologist-andrologist

Complaints - curvature of the penis to the right, inability to have sexual intercourse, periodic pain in the projection of the penis during erection.

The patient has been noticing these complaints for the last 2 years. He associates the onset of the disease with trauma to the penis during sexual intercourse. During examination by a urologist-andrologist, a dense, painless, immovable formation in the projection of the cavernous body on the right, measuring up to 2.0 × 1.0 cm, was palpated. An ultrasound dopplerography of the vessels of the penis with an intracavernous injection (the drug "Caverject") was performed - vascular blood flow is not impaired. Fibroplastic induration of the protein membrane of the cavernous body on the left was detected, measuring about 2.2 × 1.2 cm.

Surgical treatment. Flap corporoplasty of the penis was performed - excision of the fibrous plaque of the tunica albuginea of the penis with replacement of the defect with an autograft (tunica vaginalis testis). Method of surgery: With the patient lying on his back, under general anesthesia, in the area of the coronary groove of the penis, the tunica albuginea was opened by a circular incision of the skin down to the tunica albuginea. The penis was scalped to the base. Artificial erection was modulated, 1 ml of papaverine solution was injected intracavernously. During revision, in the projection of the third of the penis, in the projection of the cavernous body on the right, a compaction of the tunica albuginea was visualized - a fibrous plaque, oblong in shape, measuring 2.5 × 1.0 cm, causing deformation of the penis. A blunt and sharp method was used to resect the fibrous plaque of the tunica albuginea of the penis within the healthy tissues (the plaque is presented as fibrous density tissue), the cavernous body is exposed. Hemostasis control. Due to the large size of the defect in the tunica albuginea of the penis, a decision was made to use an autograft from the testicular tunica. A 3-cm long skin incision was made in the right scrotal chamber, the tunica vaginalis of the right testicle was exposed by blunt and sharp means. It was resected. Upon revision, the tunica vaginalis was unchanged, the appendage was of normal color, the testicle was of normal size and consistency. Partial resection of the tunica vaginalis was performed. 1 oval-shaped area measuring 2.5 × 1.0 cm was obtained. Hemostasis control, layer-by-layer suturing of the membranes of the right scrotal chamber. Using the obtained autotransplant (1 section of the vaginal membrane of the right testicle), a closure of the defect of the protein membrane of the third part of the penis in the area of resection of the fibrous plaque was performed using a twisted suture with reinforcement in 2 layers. Hemostasis control. Layer-by-layer suturing of the surgical wound to the rubber graduate. Aseptic, compression bandage.

After discharge, the patient received conservative treatment - PDE-5 inhibitors (Tadalafil), the enzyme proteolytic drug "Longidaza". Subsequently, after 1 month, the patient underwent a course of LOD-therapy.

Example 3. Patient S., born in 1970, 53 years old

I went to see a urologist-andrologist

Complaints - dorsal curvature of the penis, inability to have sexual intercourse. The patient has been noticing these complaints for the past 2 years. The onset of the disease is not associated with anything. During examination by a urologist-andrologist, a dense, painless, immovable formation is palpated along the dorsal surface in the middle third of the penis, measuring up to 2.0 × 1.0 cm. An ultrasound dopplerography of the vessels of the penis with an intracavernous injection (the drug "Caverject") was performed - vascular blood flow is not impaired. Fibroplastic induration of the tunica albuginea of the cavernous body was detected along the dorsal surface, measuring about 2.1 × 1.2 cm. Surgical treatment. Flap corporoplasty of the penis was performed - excision of the fibrous plaque of the tunica albuginea of the penis with replacement of the defect with an autograft (the vaginal membrane of the testicle). Method of surgery: With the patient in a supine position and under general anesthesia, the sheaths of the penis down to the tunica albuginea are opened by a circular incision of the skin in the area of the coronary groove of the penis. The penis is scalped to the base. Artificial erection is modulated, 1 ml of papaverine solution is injected intracavernously. During revision, in the projection of the third of the penis, along the dorsal surface, a compaction of the tunica albuginea is visualized - a fibrous plaque, oblong in shape, measuring 2.5 × 1.0 cm, causing dorsal deformation of the penis. Resection of the fibrous plaque of the tunica albuginea of the penis within healthy tissues (the plaque is presented as fibrous density tissue) is performed by blunt and sharp means, with retraction of the dorsal vessels, the cavernous body is exposed. Hemostasis control. Due to the large size of the defect in the tunica albuginea of the penis, a decision was made to use an autograft from the testicular tunica. A 3-cm skin incision was made in the right scrotal chamber, the tunica vaginalis of the right testicle was exposed by blunt and sharp means. It was resected. During revision, the tunica vaginalis was unchanged, the appendage was of normal color, the testicle was of normal size and consistency. Partial resection of the tunica vaginalis was performed. 1 oval-shaped section measuring 2.5 × 1.0 cm was obtained. Hemostasis control, layer-by-layer suturing of the membranes of the right scrotal chamber. Using the obtained autograft (1 section of the tunica vaginalis of the right testicle), a locking suture was used, with reinforcement in 2 layers, to close the defect in the tunica albuginea of the third of the body of the penis in the resection zone of the fibrous plaque. Hemostasis control. Layered suturing of the surgical wound to the rubber graft. Aseptic, compression bandage.

After discharge, the patient received conservative treatment - PDE-5 inhibitors (Tadalafil), the enzyme proteolytic drug "Longidaza". Subsequently, after 1 month, the patient underwent a course of LOD-therapy.

The proposed invention has the following advantages compared to the prototype and other known technical solutions:

- the use of a well-vascularized flap reduces the risk of infection, resorption and fragmentation in the form of fibrosis zones;

- the ability of the displaced flap to stretch and contract allows for the creation of functional comfort during erection and detumescence;

- reduction of the clinical duration of the disease and the length of the patient's stay in hospital.

Claims (1)

A method for correcting penile curvature using a free flap of the tunica albuginea of the testicle, comprising a circular incision of the skin of the penis, characterized in that the penis is skeletonized to the base, the latter is opened and excised within the healthy tissue at the site of fibrous induration of the tunica albuginea of the penis, then the defect of the tunica albuginea of the cavernous bodies is replaced with a flap, whereby a free flap is isolated from the tunica albuginea of the testicle, the defect of the tunica albuginea of the penis is closed, fixing the obtained free flap of the tunica albuginea of the testicle to the tunica albuginea of the cavernous bodies with interrupted sutures, and a wrapping suture is applied to the defect area of the tunica albuginea of the middle third of the penis body in the resection zone of the fibrous plaque.