Understanding the pathogenesis of hypospadias determines the correct tactics of the surgeon and contributes to the successful treatment of hypospadias.
Treatment of hypospadias is carried out exclusively operatively. Before surgery, it is necessary to conduct a comprehensive examination of the patient, which makes it possible to differentiate hypospadias from other disorders of sex formation. For this purpose, in addition to a general examination of the patient, karyotyping is mandatory (especially in cases where hypospadias are combined with cryptorchidism).
Operative treatment of hypospadias has the following objectives:
- complete expansion of the curved cavernous bodies providing an erection sufficient for the sexual act;
- the creation of an official urethra from tissue lacking hair follicles of sufficient diameter and length without fistulas and strictures;
- urethroplasty using the patient's own tissue with adequate blood supply, providing growth of the created urethra as physiological growth of cavernous bodies;
- moving the external opening of the urethra to the apex of the glans penis with the longitudinal location of the meatus;
- the creation of free urination without deviation and spraying of the jet;
- the maximum elimination of cosmetic defects of the penis with the aim of psychoemotional adaptation of the patient in society, especially when entering into sexual relations.
After the introduction of the latest scientific achievements in modern medicine, there are wide opportunities to revise a number of concepts in plastic surgery of the penis. The presence of microsurgical instruments, optical magnification and the use of inert suture material made it possible to minimize operational trauma and perform successful operations in children from 6 months. Most modern urologists around the world prefer a one-step correction of hypospadias at an early age. Attempts by some urologists to perform a one-stage operation in newborn boys or in children aged 2-4 months did not justify themselves. Most often, the correction of hypospadias is performed at 6-18 months. Because at this age the ratio of the size of the corpus cavernosum and the stock of plastic material (actually the skin of the penis) is optimal for performing the operational benefit.
In addition, at this age, performing corrective operations minimally affects the child's psyche. As a rule, a child quickly forgets the negative aspects of postoperative treatment, which in the future does not affect his personal development. In patients who have suffered multiple surgical interventions for hypospadias, an inferiority complex is often formed.
All types of developed technologies of surgical interventions can be divided into three groups:
- methods using the penile tissue;
- methods using the patient's tissues located outside the penis;
- methods using the achievements of tissue engineering.
The choice of method often depends on the technical equipment of the clinic, the experience of the surgeon, the age of the patient, the effectiveness of preoperative preparation and the anatomical features of the genital organs.
Algorithm for choosing the method of operative treatment of hypospadias
The choice of the method of surgical treatment directly depends on the number of methods that the surgeon has perfect control, since a variety of techniques can be used with the same form of defect with the same success. Sometimes to solve the problem there is enough meatotomy, and sometimes it is necessary to perform complex microsurgical operations, therefore the defining moments for choosing the method are the following:
- location of the hypospadic meatus;
- narrowing of the meatus;
- size of the prepuce bag;
- the ratio of the size of the cavernous bodies and the skin of the penis;
- dysplasia of the skin of the ventral surface of the penis;
- degree of curvature of cavernous bodies;
- the size of the glans penis;
- depth of groove on the ventral surface of the glans penis;
- degree of rotation of the penis;
- the size of the penis;
- presence of synechias of the foreskin and degree of their severity;
- topic of the trunk of the penis, etc.
Now more than 200 methods of operative correction of hypospadias are known. However, this article presents operations that have a fundamentally new direction in plastic genital surgery.
The first attempt of operative correction of hypospadias in 1837 was undertaken by Dieffenbach. Despite the interesting idea of the operation itself, unfortunately, it was not successful.
The first successful attempt of urethroplasty was performed by Bouisson in 1861 using rotated scrotum skin.
In 1874, Anger used an asymmetrical displaced flap of the ventral surface of the trunk of the penis to create an official urethra.
In the same year, Duplay used a tubularized ventral skin flap for the plasty of the urethra on the Thiers principle, proposed for the correction of trunk epispadias in the 60s of that century. The operation was carried out in one or two stages. In the distal form of hypospadias, the operation was performed in one stage, in cases with proximal forms, the urethra plastic was performed a few months after the preliminary dilatation of the trunk of the penis. This operation has become widespread throughout the world, and now many surgeons who do not know the technique of a one-stage correction for hypospadias use this technology.
In 1897, Nove and Josserand described the method of creating an official urethra using an autologous free skin flap. Withdrawn from the non-haired part of the body surface (inner surface of the forearm, abdomen).
In 1911 L. Ombredan attempted a full-stage correction of the distal form of hypospadias in which the official urethra was created on the principle of flip-flap using the skin of the ventral surface of the penis. The resulting wound defect was covered with a displaced split precutial flap according to the principle developed by Thiersch.
In 1932, Mr .. Mathieu. Using the principle of Bouisson. Performed a successful correction of the distal form of hypospadias.
In 1941, Humby proposed using a mucous cheek to create a new urethra.
In 1946 Cecil, using the principle of Duplay and Rosenberger in 1891, performed a three-stage urethral plastic surgery with a stem-and-socket form using the stem-and-socket anastomosis in the second stage of the surgical manual.
Memmelaar in 1947 described the method of creating an official urethra using a free flap of the mucosa of the bladder. In 1949 Browne described the method of distal urethroplasty without closing the internal area of the official urethra, counting on the independent epithelization of the non-tubularized surface of the artificial urethra.
The founder of a number of operations aimed at creating an official urethra using a vascular bundle was Broadbent who in 1961 described several variants of such operations.
In 1965, Mustarde developed and described an unusual method of urethroplasty using a tubularized rotated ventral skin flap with tunneling of the glans penis.
In the years 1969-1971. N. Hodgson and Asopa developed the idea of Broadbent and created a number of original technologies that allow performing correction of severe forms of hypospadias in one stage.
In 1973, Durham Smith developed and implemented the principle of a mixed de-epithepatic flap, which later became widely used throughout the world in the correction of hypospadias and excision of urethral fistulas.
In 1974, Cities and MacLaughlin first applied and described an artificial erection test in which, after the turnstile was placed on the base of the penis, sodium chloride was injected intravenously (sodium chloride isotonic solution for injection 0.9%). This test allowed an objective assessment of the degree of curvature of the trunk of the penis.
In 1980, Duckett described the option of a one-stage correction of hypospadias using the skin of the inner leaf on the vascular pedicle. In 1983, Koyanagi described the original method of a one-stage correction of the proximal form of hypospadias with a double vertical urethral suture.
In 1987, Snyder developed a method for urethroplasty using the inner sheet of the preproduction on the vascular pedicle, according to the principle of two flaps, or onlay-urethroplasty.
In 1989, Rich applied the principle of longitudinal dissection of the ventral flap in distal hypospadias in combination with Mathieu technology, performing urethroplasty with less tissue tension, thereby reducing the likelihood of postoperative complications.
In 1994, Snodgrass developed the idea, using the same method of dissecting the ventral surface in combination with the Duplay method.
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Technique of operation
To provide technical aids for surgical correction of hypospadias urologist must possess in-depth knowledge of the penis anatomy This knowledge allows optimum spread cavernous body, carve out a skin flap to be used to create an artificial urethra while preserving the vascular bundle, and close the wound surface without damage to important anatomical structures . Underestimation of this problem can lead to serious complications, up to disability. In many respects the successful treatment of hypospadias depends on the technical equipment. Typically, for rapid correction of hypospadias, urologists use a binocular magnifier with a 2.5-3.5-fold magnification or a microscope, as well as microsurgical instruments. Urn used bryushisty scalpel 15. Anatomic and surgical forceps with a minimum size of gripping tissues atraumatic needle holder, forceps type "Hummingbird", unidentate and bidentate hooks small and atraumatic absorbable monofilament suture 6 0-8 0 The operation should be avoided crushing of tissues used to create an official urethra. To this end, you need to use small hooks or microsurgical retractors. For long-term fixation of tissues in a particular position, it is advisable to use yarn-holders that do not cause damage to the skin flap.
When correcting any form of hypospadias, it is desirable to perform complete mobilization of cavernous bodies in the space between the superficial fascia of the penis and the fascia of Buck. This manipulation allows you to perform a complete revision of the cavernous bodies and carefully excise the fibrous chord, which even in the distal forms of hypospadias can be located from the head to the penoscallal angle, limiting further growth of the penis. Mobilized skin of the penis makes it possible to more freely perform the stage of closing the cavernous bodies, excluding the possibility of tissue tension. One of the main principles of plastic surgery of the genital organs, contributing to the achievement of a successful result, remains the principle of loosely laid flaps without tension of the tissues.
Sometimes, after mobilization of the skin of the penis, signs of microcirculation disturbance in the flap are noted. In these cases, you should postpone the stage of urethra plastic surgery the next time or, after performing the urethra plastic, move the ischemic tissue area away from the vascular pedicle feeding the urethra, to avoid vessel thrombosis.
After the stage of urethra plastic surgery, it is desirable to shift the line of subsequent sutures to prevent the formation of urethral fistulas in the postoperative period. This method more than 100 years ago was used by Thiersch when correcting the triceps epispadia.
Most urologists agree that in the process of performing an operational manual, it is necessary to minimize the use of an electrocoagulator or to apply minimal coagulation regimens. Some surgeons use a 0.001% epinephrine solution (epinephrine) to reduce tissue bleeding. Spasm of peripheral vessels prevents in some cases an objective assessment of the condition of skin flaps and can lead to erroneous tactics during the operation. It is much more effective to use a tourniquet superimposed on the base of cavernous bodies in order to achieve the same effect. However, it should be noted that it is necessary to remove the tourniquet from the cavernous bodies every 10-15 minutes for a while. During the operation, it is recommended to irrigate the wound with antiseptic solutions. Sometimes urologists with a prophylactic goal use a single injection of a daily dose of a broad-spectrum antibiotic in a dose appropriate to age.
At the end of the operative allowance, an aseptic bandage is applied to the penis. Most surgeons tend to use bandages with glycerol (glycerin) in combination with a porous elastic bandage. An important point - the imposition of a loose gauze bandage, impregnated with sterile glycerol (glycerin), in one layer in a spiral from the head to the base of the penis. Then, a thin, porous, elastic bandage is applied over the gauze bandage (for example, a bandage of M M C Mon). A strip of 20-25 mm wide is cut from the bandage. Then, according to the same principle, one layer of bandage is applied spirally from the head to the base of the penis. In the process of applying the bandage, there should be no bandage tension. He should only repeat the contours of the trunk of the penis. This technique allows you to maintain adequate blood supply in the postoperative period, while limiting the swelling of the penis. By the 5th-7th day of the postoperative period, the swelling of the penis is gradually decreasing, and the bandage is shortened due to its elastic properties. The first change of dressings is made, as a rule, on the 7th day in the event that it is not impregnated with blood and retains its elasticity. The condition of the dressings is assessed visually and with the help of palpation. The bandage, impregnated with blood or lymph, quickly withers and does not fulfill its function. In this case, it should be changed, pre-moistened with antiseptic solution and soak for 5-7 minutes.
Removal of urine in the postoperative period
An important aspect in plastic surgery of the genital organs remains the derivation of urine in the postoperative period. For a long history of genital surgery, this problem was solved by various methods - from the most complicated drainage systems to tran- sporeal abnormalities. To date, most urologists consider it necessary to drain the bladder for a period of 7 to 12 days.
Many urologists use cystostomic drainage in the postoperative period, sometimes in combination with transurethral derivation. Some authors consider the optimal method of solving this problem puncture urethrostomy, which provides adequate drainage of urine.
The overwhelming majority of urologists consider effective urinary diversion, which allows preserving the bandage on the penis without contact with the urine for a long time, an obligatory component of a set of measures aimed at preventing possible complications.
Long-term experience of operative correction of hypospadias objectively proves the rationality of using transurethral urine diversion in patients with any form of defect.
An exception may be patients who have used the achievements of tissue engineering for the purpose of creating an official urethra. In this group of patients it is logical to use a combined urine diversion - puncture cystostomy in combination with a transurethral lead for up to 10 days.
As an optimal catheter for drainage of the bladder, it is recommended to use a urethral catheter with an end and side holes No. 8 CH. The catheter should be inserted into the bladder no deeper than 3 cm in order to prevent involuntary contraction of detrusor and leakage of urine.
Do not recommend using catheters with a balloon that causes irritation of the neck of the bladder and a constant reduction in detrusor. In addition, the extraction of a Foley type catheter increases the risk of damage to the official urethra. The reason for this is that the balloon, bloated within 7-10 days, in the postoperative period is not able to decay to its original state. The overstretched wall of the balloon leads to an increase in the diameter of the extracted catheter, which may contribute to the partial or complete rupture of the official urethra.
In some cases, leakage of urine in addition to the urethral catheter is maintained, despite the optimal location of drainage. This circumstance is usually associated with the posterior location of the neck of the bladder, resulting in constant irritation of the wall of the bladder by a catheter. In these cases, it is more efficient to leave the stent in the urethra, which is proximal to the hypospadic meatus, in combination with the bladder drainage through the puncture cystostomy [Faizulin AK 2003].
The urethral catheter is fixed to the head of the penis at a distance (15-20 mm) for an easier crossing of the ligature when the catheter is removed. It is advisable to apply a duplicate nodal suture over the edge of the bandage and connect it with an additional node with a urethral catheter. Thus, the urethral catheter will not pull behind the glans penis, causing the patient pain. The outer end of the catheter is connected to the urinary receiver or taken to a diaper or diaper.
Usually the urethral catheter is removed in the interval from 7 to 14 days, paying attention to the nature of the jet. In a number of cases, it becomes necessary to boogie an official urethra. Since this manipulation is extremely painful, it is performed under anesthesia. After the patient is discharged from the hospital, a follow-up check should be carried out after 1, 2 weeks, after 1, 3 and 6 months. And then - once a year until the end of penis growth, emphasizing the parents' attention to the nature of the jet and erection.
Draining of the postoperative wound is performed only in those cases when it is impossible to apply a compression bandage to the entire surgical intervention zone: for example, if the urethral anastomosis is imposed proximal to the penoscallal angle.
To this end, use a thin tube No. 8 CH with multiple lateral holes or a rubber graduate that is removed from the side of the skin seam line. Usually the drainage is removed the next day after the operation.
Characteristics of individual methods of operative correction of hypospadias
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Indication for the use of this technique is the location of the hypospadic meatus in the region of the coronal sulcus or glans penis without ventral deformation of the latter.
The operation begins with a bordering incision around the glans penis, retreating 4-5 mm from the coronal sulcus, and on the ventral surface the incision is made 8 mm proximal to the hypospadic meatus.
When carrying out the incision, maximum care must be taken in connection with the thinning of the tissue of the distal part of the urethra, over which the incision is made, and with the threat of formation of the urethral fistula in the postoperative period.
Cut the skin to the full thickness before the fascia Buck. After this, mobilize the skin of the penis, allowing you to keep the vessels that nourish the skin. After dissection of the skin of the penis itself using tweezers, lift the superficial fascia and dissect with vascular scissors. Fabrics are diluted bluntly between the superficial fascia and the fascia of Buck. With the correct dissection of the fascia, mobilization of the skin occurs virtually bloodless.
Then, gently with the help of vascular scissors dilute the soft tissues of the penis during the cutaneous incision, gradually moving from the dorsal surface to the sides of the penis in the interfascial space. Particular attention should be paid to manipulations in the area of the ventral surface, since it is here that the skin of the penis, the superficial fascia and the gallbladder (fascia Buck) are soldered intimately, which can lead to injury of the urethra wall.
The skin is removed from the trunk of the penis to the base, like a stocking, which allows eliminating the dermal torso accompanying sometimes distal forms of hypospadias, as well as creating a mobile skin flap.
At the next stage, a longitudinal incision is made along the scaphoid fossa of the penis, including the dorsal wall of the hypospadic meatus for the purpose of meatotomy, since often the distal forms of hypospadias are accompanied by a materal stenosis.
The incision is made quite deep to cross the connective tissue jumper, located between the hypospadic meatus and the distal edge of the scaphoid fossa. Thus, the surgeon achieves smoothing of the ventral surface of the head, eliminating the ventral deviation of the jet during urination.
The wound on the dorsal wall of the meatus assumes a rhomboid shape, which ensures the elimination of any meal constriction. Sew the ventral wound 2-3 transverse sutures with a monofilament thread (PDS 7/0).
For glanuloplasty use a single-tooth hook or microsurgical forceps, with which the skin edge proximal to the hypospadic meatus is raised towards the head in such a way that the ventral edge of the operating wound resembles the inverted V.
Lateral margins of the wound on the head are stitched by 2-3 U-shaped or nodal sutures without tension on the urethral catheter of the age-related size.
When the wound defect is closed with the remnants of the mobilized skin, there is no single method that is universal for all cases of skin plasty, since the degree of dysplasia of the ventral skin, the amount of plastic material on the trunk of the penis, and the size of the prepuce bag vary considerably. Most often used method of closing the skin defect proposed by Smith, which produces a splitting of the prepuce bag with a longitudinal cut of the latter along the dorsal surface. Then the formed skin flaps are wrapped around the trunk of the penis and stitched on the ventral surface between each other or one under the other.
In most cases, the remaining skin is sufficient to free the closure of the defect without any movement of the tissue, and a compulsory moment from the cosmetic point of view is the excision of the remnants of the prepuce.
In some cases, the Tiersh-Nesbit principle is used to close the ventral wound defect, in which a hole is created in the avascular area of the dorsal skin flap through which the glans penis is moved dorsally and the defect on the ventral surface is covered with a tissue of the fenestrated prepuce. Then the coronal cutaneous edge of the wound is stitched with the edge of this opening, and the wound on the ventral surface of the trunk of the penis is sutured longitudinally with a continuous seam.
The method of urethroplasty with a megalomyate without the use of a prep (MIP)
Indication for the use of this technology is the coronary form of hypospadias without ventral deformation of the trunk of the penis, confirmed by the test of an artificial erection.
The principle of operation is based on Tiersch-Duplay technology without the use of tissue prepuce. The operation is started from the U-shaped incision along the ventral surface of the glans penis with the bordering of the mega-meatus along the proximal margin (Fig. 18-89a). Sharp scissors neatly secrete the lateral walls of the future urethra without crossing the split spongy body of the urethra. Most often, there is no need for deep isolation of the walls, since the deep navicular fossa allows the formation of a new urethra without the slightest tension.
The urethra is formed on the urethral catheter. The transurethral catheter should move freely in the lumen of the created canal. As a suture material, the use of a monofilament absorbable yarn 6 / 0-7 / 0 is optimal.
For the prevention of paraurethral urine swabs, a continuous precision urethral suture is used in the postoperative period. Similarly, a dermal suture is applied.
Movement of the urethra with glanuloplasty and plasty in the distal forms of hypospadias
Indications for use of this method are the head and coronary forms of hypospadias without signs of dysplasia of the distal urethra. At the beginning of the operation, the bladder is catheterized. The operation begins with a submeal crescent incision of the skin, which is produced 2-3 mm below the meatus.
This incision is prolonged vertically, skirting the meatus on both sides and continuing upward until they merge at the apex of the glans penis. Meatus is excreted in a sharp and blunt way, then the distal section of the urethra is mobilized. Behind the urethra is the fibrous layer. It is very important not to lose the layer in the process of allocation of the urethra and not to damage its wall and cavernous bodies. At this stage of the operation, special attention is paid to maintaining the integrity of the urethra and thin skin of the penis, which reduces the risk of forming postoperative fistulas. Mobilization of the urethra is considered complete when the urethral meatus reaches the tip of the glans penis without tension. For the excision of the remaining chord, two incisions are made near the coronal sulcus, each of which is about 1/4 of its circumference. After the full mobilization of the urethra, it is reconstructed. Meatus is sutured to the tip of the glans penis with a discontinuous suture. The head is closed over the displaced urethra with nodal sutures. The skin of the prepuce is given a natural appearance by cross-cutting its ventral part from both sides and the vertical joint. Thus, the head is closed with a restored foreskin. After the operation, the penis acquires a normal appearance, the meatus is at the tip of the head, the skin of the prepuce fringes the head. The transurethral catheter is removed on the 7th day after the operation.
The method of urethroplasty of the Mathieu type (1932)
Indication for the use of this technology is the head form of hypospadias without deformation of the trunk of the penis with a well developed scaphoid fossa, in which the urethral defect is 5-8 mm in combination with the full-valued skin of the ventral surface that does not show signs of dysplasia.
The operation is performed in one step. Two parallel longitudinal incisions are made laterally along the lateral edges of the scaphoid fossa laterally than the hypospadic meatus and proximal to the latter by the length of the urethral tube deficit. The width of the skin flap is half the length of the circumference of the created urethra. The proximal ends of the cuts are connected together.
In order to reliably hide the created urethra, mobilize the spongy tissue of the glans penis. This is a very delicate task, it is performed by carefully cutting through the connective tissue bridge between the cavernous body of the head and the cavernous bodies until the rotated flap is placed in the newly created niche and the head edges freely close above the formed urethra.
The proximal end of the skin flap is mobilized to the hypospadic meatus and rotated distally, overlapping the base flap so that the corners of the apex of the selected flap coincide with the tops of the incisions on the flap-flap flap. The flaps are sewn together by a lateral continuous intradermal precision suture from the top of the head to the base of the flap on the urethral catheter.
The next stage, the mobilized edges of the glans penis are sewn with nodular sutures over the formed urethra. Surpluses of preputial tissue are resected at the level of the coronal sulcus. The operation is completed by the application of a compression bandage with glycerol (glycerin). The catheter is removed on the 10th-12th day after the operation.
Method of urethroplasty of the Tiersch-Duplay type
Indication for this operation is a coronary or head form of hypospadias in the presence of a well developed head of the penis with a pronounced scaphoid furrow.
The principle of operation is based on the creation of a tubularized flap on the ventral surface of the penis and therefore has well-founded contraindications. This surgery is undesirable in patients with stem and proximal forms of hypospadias. Because the urethra created by the principle of Tiersch and Duplay. Is practically deprived of the main feeding vessels and accordingly has no prospects of growth. Children with proximal forms of hypospadias, operated on this technology, suffer from the syndrome of "short urethra" in the pubertal period. In addition, the frequency of postoperative complications after using this technique is highest.
The operation begins with a U-shaped incision along the ventral surface of the penis with fringing of the hypospadic meatus along the proximal margin. Then mobilize the edges of the wound on the head, penetrating the connective tissue septum between the spongy tissue of the head and the cavernous bodies. Then the central flap is sewed into the tube on catheter No. 8-10 CH with a continuous precision suture, and the edges of the head are stitched together by nodular seams over the formed urethra. The operation is completed by the application of a compression bandage with glycerol (glycerin).
Method of urethroplasty using the mucous membrane of the cheek In 1941 GA Humby first proposed the use of the mucous membrane of the cheek as a plastic material in the operative correction of hypospadias. Many surgeons used this method, but J. Duckett actively promoted the use of the mucous cheek to reconstruct the urethra. Many surgeons avoid using this technology due to the high frequency of postoperative complications, which varies from 20 to 40%.
There are single-stage and two-stage operations in the reconstruction of the urethra with the use of the mucous membrane of the cheek. In turn, one-stage operations are divided into three groups:
- urethral plastic by a tubularized flap of the buccal mucosa;
- urethra plastic by the "patch" principle;
- combined method.
In any case, initially, the mucous cheek is removed. Even in an adult, it is most possible to obtain a flap measuring 55-60x12-15 mm. It is more convenient to take a flap from the left cheek, if the surgeon is right-handed, standing to the left of the patient. It should be remembered that the flap should be taken strictly from the middle third of the side of the cheek in order to avoid injuring the ducts of the salivary glands. An important condition should be considered remoteness from the corner of the mouth, since the postoperative scar can lead to deformation of the mouth line. Ransleu (2000), for the same reason, does not recommend the use of the lower lip for mucosa. In his opinion, the postoperative scar leads to deformation of the lower lip and a violation of diction.
Before taking the flap, inject 1% with a solution of licorice a and on or 0.5% with a solution of procaine (novocaine) under the mucous membrane of the cheek. Sharp path cut out a flap and sutured wound defect with nodular sutures, using chrome-veined catgut threads 5/0. Then. Also by a sharp path, remove the remains of the underlying tissues from the inner surface of the mucosa. Then use the treated flap for the intended purpose. In those cases where the urethra is formed by the principle of a tubular flap, the latter is formed on the catheter by a continuous or nodular suture. Then the formed urethra is sewed with the hypospadic meatus end to end and creates a meatus, closing the edges of the dissected head over the urethra.
When creating the urethra by the "patch" principle, it should be remembered that the size of the implantable mucosal flap directly depends on the size of the underlying skin flap. Totally they must correspond to the age diameter of the urethra formed. The flaps are sewn together by a continuous side seam using absorbable yarn 6 / 0-7 / 0 on the urethral catheter. The wound is closed with the remains of the skin of the trunk of the penis.
Less often use the mucous membrane of the cheek with a formed deficit of plastic material. In such situations, part of the artificial urethra is formed by one of the described methods, and the deficit of the urethral tube is eliminated with the help of a free flap of the mucous membrane of the cheek.
Similar operations in patients with complete growth of cavernous bodies are certainly of interest. However, with regard to pediatric urological practice, the question remains open, since it is impossible to exclude the lag in the development of the official urethra from the growth of the cavernous bodies of the penis. In patients with hypospadias, operated at an early age by this technology, the development of a syndrome of the short urethra and a secondary ventral deformation of the trunk of the penis is possible.
Method of urethroplasty using a tubularized inner sheet Prepiction on the vascular pedicle
The Duckett method is used for a one-step correction of the posterior and middle forms of hypospadias, depending on the stock of plastic material (the size of the foreskin). Technology is also used in severe forms of hypospadias with severe skin deficit in order to create an official urethra in the scrotal and scrotal bone. An important point is the creation of a proximal fragment of the urethral tube from the skin, which is devoid of hair follicles (in this case, from the inner leaf of the foreskin), with the prospect of distal urethroplasty by local tissues. The defining moment is the size of the prepuce bag, which limits the plasticity of the artificial urethra.
The operation begins with a bordering incision around the head of the penis retreating 5-7 mm from the coronal sulcus. The skin is mobilized to the base of the penis according to the principle described above. After mobilization of the skin of the penis and excision of the fibrous chord, an assessment is made of the true deficit of the urethra. Then a transverse skin flap is cut from the inner sheet of the foreskin. The incision on the inner surface of the prepuce is carried out to the depth of the skin of the inner sheet of the foreskin. The length of the flap depends on the size of the defect of the urethral tube and is limited by the width of the preputial sac. The flap is sewn into the tube on the catheter by a continuous precision intradermal suture using atraumatic monofilament resorbable filaments. The remains of the inner and outer leaves of the foreskin are exfoliated in the avascular zone and used subsequently to close the wound defect of the ventral surface of the penis. An important stage of this operation is a careful mobilization of the official urethra from the external epithelial plate without damaging the vascular pedicle. Then the mobilized urethral tube is rotated to the Viennese surface to the right or to the left of the stem of the penis, depending on the location of the vascular pedicle in order to minimize the inflection of the feeding vessels. The formed urethra is stitched with the hypospadic meatus by the end-to-end type with a nodal or continuous suture.
An anastomosis between the urethra and the head of the penis is performed using the Hendren method. To do this, the epithelial layer is cut to the cavernous bodies, after which the distal end of the created urethra is laid in the formed hollow and sewn with the edges of the scaphoid fossa with nodular sutures over the formed urethra. Sometimes children with a small head of the penis can not close the edges of the head. In these cases, Browne technology, described in 1985 by V. Belman, is used. In the classical version, tunneling of the glans penis was used to create an anastomosis of the distal part of the official urethra. According to the author, stenosis of the urethra occurred with a frequency of more than 20%. The use of the principle of Hendren and Browne makes it possible to reduce the frequency of this postoperative complication 2-3 times. To close the cavernous bodies of the penis, the previously mobilized skin of the outer sheet of the prepuce, cut on the dorsal surface and rotated to the ventral surface according to the Culp principle, is used.
Method of islet urethroplasty on the vascular pedicle by the principle of patch Snyder-III
This technology is used in patients with coronary and trunk forms of hypospadias (anterior and middle forms according to Barcat) without curvature of the trunk of the penis or with minimal curvature. Patients with a pronounced curvature of the trunk of the penis need more often the intersection of the ventral skin pathway for the complete spreading of the cavernous bodies. An attempt to straighten the penis with a pronounced fibrous chord by dorsal plication leads to a significant shortening of the length of the trunk of the penis.
The operation is not indicated in patients with hypoplastic foreskin. Before the operation, it is necessary to evaluate the correspondence between the dimensions of the inner sheet of the prepuce and the distance from the hypospadic meatus to the top of the head.
The operation begins with a U-shaped incision along the ventral surface of the penis with fringing of the hypospadic meatus along the proximal margin. The width of the ventral flap is formed not less than half the age of the circumference of the urethra. Then the incision is prolonged to the sides, skirting the head of the penis, retreating 5-7 mm from the coronal sulcus. Skin mobilization is performed according to the method described above. Fibrous chord is excised on the sides of the ventral flap. In the case of a remaining curvature of the trunk of the penis, plication is performed along the dorsal surface.
The next step from the inner sheet of the prepuce is a transverse cutaneous flap corresponding to the size of the ventral flap. The incision is made to the depth of the skin of the inner leaf of the foreskin itself. Then the precutaneous flap is mobilized in the avascular zone, stratifying the sheets of the prepuce. The cutaneous "island" is mobilized until it moves to the ventral surface without tension. The flaps are sewed together by a continuous subcutaneous suture on the urethral catheter. Initially, suture the mesenteric margin, then the opposite one. The mobilized edges of the head are sewn with nodular sutures over the formed urethra. Nude cavernous bodies are covered with the remains of mobilized skin.
Combined method of urethroplasty according to the FIII-Duplau method
Indication for surgery - scrotal or perineal form of hypospadias (posterior according to the classification of Bacsat), in which the meatus is initially located on the scrotum or in the perineum at a distance of at least 15 mm proximal.
The operation begins with a bordering incision around the glans penis, retreating 5-7 mm from the coronal sulcus. On the ventral surface, the incision is prolonged longitudinally to the penoscallal angle. Then, the skin of the penis is mobilized before the transition to the scrotum along the ventral surface. On the dorsal and lateral surfaces, skin mobilization is performed up to a foam-symphisic space with a lig. Suspensorium penis.
At the next stage, urethroplasty is produced using F III technology, and the gap from the hypospadic meatus to the penoscallal angle is performed using the Duplay method. N. Hodgson offers fragments of the official urethra to sew end to end on the urethral catheter No. 8 CH. It is known that the number of postoperative complications with the use of terminal anastomoses reaches 15-35%. To minimize complications, the principle of onlay-tube or onlay-tube-onlay, described below, is currently used. The wound defect is sutured with a continuous suture seam. The operation is traditionally completed by the application of bandages with glycerol (glycerin).
The combined principle of urethroplasty for proximal forms of hypospadias can also consist of an islet tubularized skin flap from the inner flesh of the foreskin (the Duckett principle) and the Duplay method, as well as the Asopa technology in combination with the Duplay method.
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Method of urethroplasty F-II
This method of operative correction of hypospadias is based on the principle developed by N. Hodgson (1969-1971). But the essence is a modification of the known method. It is used in front and middle forms of hyposodium.
In 50% of patients with a distal form of hypospadias, congenital stenosis of the meatus is diagnosed. Surgery is initiated with a bilateral lateral meatotomy according to Duckett. The length of the incisions varies from 1 to 3 mm, depending on the age of the patient and the severity of stenosis. The incision line is pre-crushed with a haemostatic clamp of the "mosquito" type, and after cutting the meatus, a nodal suture is applied to the incision area, but only when the leakage of blood from the edges of the wound is noted. After the removal of stenosis, the meatus proceeds to the main stage of the operational aid.
On the ventral surface of the penis, a U-shaped incision is made with fringing of the meatus along the proximal margin. In the classical version, the width of the base flap is made equal to half the length of the circumference of the urethra. The modified incision on the ventral surface is performed along the edge of the scaphoid fossa, which does not always correspond to half the length of the urethra circumference. Most often the shape of this incision resembles a vase with an enlarged throat, a narrow neck and an enlarged base.
In these cases, the opposite flap (flap) is formed in such a way that when a patch is applied, a perfectly smooth tube is obtained. In those places where the extension was formed on the base flap, a narrowing is created on the donor flap, and vice versa.
A figured incision on the ventral surface is made to maximize the preservation of the head tissue for the final stage of glanuloplasty and more convenient access to the connective tissue intercavernous groove separating the spongy tissue of the glans penis and cavernous bodies.
The mobilization of the skin of the penis is performed by standard technology up to the foam-scrotal angle. In those cases where the deep dorsal vein of the penis has a perforating vessel associated with the skin flap, surgeons try not to cross it. Maximum preservation of venous angioarchitectonics of the penis allows to reduce venous stasis and, accordingly, to reduce the degree of edema of the penis in the postoperative period. For this purpose, the perforating vessel is mobilized to the level where the dorsal flap does not fit freely, without the slightest tension after the skin flap is moved to the ventral surface. In cases where mobilization of the flap is not possible due to the tension of the vessel, the vein is bandaged and dissected between the ligatures without coagulation. Coagulation of the perforating vessel can lead to thrombosis of the main venous trunks.
A pre-patch for the formation of the urethra is cut out for the thickness of the skin of the outer leaf of the prepuce. Dissecting exclusively the skin without damaging the subcutaneous tissues, rich in blood vessels that feed the prechial flap.
The trunk of the penis is moved according to the Tiersch-Nesbit technique. Given the presence of meatotomic incisions, it became necessary to modify the principle of sewing skin flaps. At the same time, the base nodal seam is imposed on 3 hours of the conditioned dial from the right edge of the meatus, and then during the suture of the urethral flaps the dorsal flap is sutured to the belly coat in the immediate vicinity of the ventral margin. This technique allows you to create a sealed urethral suture line without technical complications and to avoid urine streaks.
According to the method proposed by N. Hodgson, the ventral surface of the glans penis remains a pre-manufactured skin, which creates an obvious cosmetic defect with a good functional result. Later on, when the patient enters into sexual life, this kind of head causes tactless questions and even censure from the sexual partners, which, in turn. Sometimes leads to nervous breakdowns and development of an inferiority complex In a patient who underwent surgery.
In the modification of the final stage of this operation (F-II) offer a solution to this problem. The essence lies in the de-epithelization of the distal department of the official urethra by means of microsurgical scissors and the stitching of the edges of the head of the penis over the formed urethra, this technique allows imitating the natural appearance of the glans penis.
For this, the microsurgical scissors bent along the plane produce an excision of the epidermis without capturing the underlying tissues in order to maintain the vessels of the skin flap, having retreated 1-2 mm from the official meatus, meepithelization is performed to the projection level of the coronal sulcus. Then the lateral edges of the wound on the head of the penis are stitched together over the junctions created by the urethra without tension of the dermal tissue, thus, it is possible to close the ventral surface of the glans penis, which allows to maximize the appearance of the glans penis to the physiological state. The final stage of the operation does not differ from the standard method described above.
The method of urethroplasty with hypospadias without hypospadias of type IV (F-IV, FV)
One of the options for correction of hypospadias without hypospadias of type IV is the replacement technology for the fragment of the dysplastic urethra on the basis of operations such as N. Hodgson (F-IV) and Ducken (F-V). The principle of operation is to maintain the bulbous urethra and substitution Dysplastic fragment stem portion of the urethra from the skin insertion dorsal surface of the penis or the prepuce for the inner layer pedicled double urethral anastomosis onlay-tube-onlay.
Operation F-IV begins with a bordering incision around the glans penis. The skin on the ventral surface with hypospadias without hypospadias is often not changed, therefore, no longitudinal incision is made along the ventral surface. The skin from the penis is removed as a stocking to the base of the trunk. The excision of superficial fibrous cords is performed. Then resected the dysplastic urethral tube, devoid of the corpus cavernosum, from the coronary groove until the beginning of the spongy body of the urethra. In some cases, the fibrous chord is located between the dysplastic urethra and the cavernous bodies. Chordu is excised without any problems due to wide access. The degree of rectification of the trunk of the penis is determined with the help of an artificial erection test.
The next step on the dorsal surface of the skin flap is a rectangular cutaneous flap, the length of which corresponds to the size of the urethral defect, and the width to the length of the circumference of the urethra, taking into account the age of the patient.
Then, in the proximal and distal part of the created flap, two openings are formed to further move the trunk of the penis. The epithelial flap is sewn on the catheter by a continuous suture, retreating 4-5 mm from the ends of the flap. This method allows to increase the cross-sectional area of terminal anastomoses and, accordingly, to reduce the frequency of stenosis of the urethra, since the experience of operative treatment of hypospadias has shown that in almost all cases the narrowing of the urethra occurred precisely in the region of the terminal joints.
Then the penis is moved along the Nesbit twice: initially through the proximal opening to the dorsal surface, and then through the distal opening to the ventral side. The last movement is preceded by the application of an anastomosis of the type of onlay-tube between the proximal end of the official urethra and the hypospadic meatus. After the second movement of the trunk of the penis through the distal aperture, a distal anastomosis is placed between the outflowing end of the new urethra and the leading end of the head part of the own urethra by the tube-onlay principle similar to the first. Urethral anastomoses are applied to the urethral catheter No. 8-10 SN.
To close the skin defect on the dorsal surface of the penis, sparing mobilization of lateral margins of the dorsal flap wound is performed. Then the wound is closed by stitching the edges together with a continuous seam. The skin residues around the head are stitched with the distal edge of the mobilized flap also continuously. The defect on the ventral surface of the penis is covered with a longitudinal intradermal suture. When performing urethroplasty, one should avoid the slightest tension of the tissue, which leads to marginal necrosis and divergence of the seam line.
To correct hypospadias without hypospadias in combination with dysplasia of the drainage canal, a modified Duckett (FV) operation can also be used.
The determining factor for this operation is the presence of a well developed prepuce, in which the width of the inner leaf is sufficient to create the missing fragment of the urethra. The distinctive moment of this operation in comparison with the classical operation of Duckett is the preservation of the head section of the urethra with a double urethral anastomosis of the type of onlay-tube-onlay after the creation of the official urethra from the inner sheet of the prepuce and its transfer to the ventral surface of the penis. Closure of the skin defect is carried out according to the principle described above.
A method of urethroplasty using a side flap (F-VI)
This modification of the operation Broadbent (1959-1960)). The principal difference of this technology lies in the total mobilization of cavernous bodies in patients with posterior hypospadias. The method also involves the separation of the skin flap used to create an official urethra with the hypospadic meatus. In technology Broadbent used urethral anastomosis on the principle of Duplay, and in a modified version, the principle of end-to-end, onlay-tube or onlay-tube-onlay.
The operation begins with a bordering incision around the glans penis. Then the incision is extended along the ventral surface to the hypospadic meatus with the border of the latter, retreating 3-4 mm from the edge. After mobilization of the skin of the penis to the base of the trunk with the intersection of lig. Suspensorium penis produces an excision of the fibrous chord.
Estimating the true deficit of the urethra after the penis is straightened it is obvious that it, as a rule, considerably exceeds the stock of plastic material of the trunk of the penis proper. Therefore, to create an official urethra along the entire length, one of the edges of the cutaneous wound is used, which has minimal signs of ischemia. To do this, four holders are placed in the intended zone of the flap creation. Corresponding to the length of the deficit of the urethra. Then the marker marks the boundaries of the flap and makes cuts along the outlined contours. The depth of the cut along the side wall should not exceed the thickness of the skin itself, in order to maintain the vascular pedicle. The shape of the flap is created by the onlay-tube-onlay technology described above.
A particularly important point is the isolation of the vascular pedicle, since the thickness of the full-fledged flap does not always make it possible to perform this manipulation easily. On the other hand, the length of the vascular pedicle should be sufficient for the free rotation of the new urethra on the ventral surface with the reversal of the urethral suture line toward the cavernous bodies. The urethra is formed by the principle of onlay-tube-onlay. After moving the urethra to the ventral surface, an axial rotation of the trunk of the penis sometimes occurs 30-45 *, which is removed by rotating the skin graft in the opposite direction. The operation is completed by the application of a compression bandage with glycerol (glycerin).
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The method of correction of hypospadias according to the principle of onlay-tube-onlay and onlay-tube (F-VllI, F IX)
Stenosis of the urethra is one of the most formidable complications that arise after its plasty in the back and middle forms of hypospadias. Buzhirovanie the urethra and endoscopic dissection of the narrowed part of the urethra often lead to a relapse of stenosis and, ultimately, to a second operation.
Stenosis of the urethra is usually formed in the area of the proximal urethral anastomosis superimposed on the principle of end to end. In the search for a rational method of correction of the defect, a method was developed that allows avoiding the use of terminal anastomosis called onlay-tube-onlay.
The operation is started from the figured section. To do this, a flap resembling the letter and is cut out along the ventral surface of the glans penis. The width of the flap is formed according to the age diameter of the urethra, it is half the length of the circumference of the urethra. Then the incision is extended along the midline of the ventral surface of the trunk from the base of the U-shaped incision to the hypospadic meatus. Retreating h = 5-7 mm from its distal margin. A cutaneous flap with an angle in the distal direction is cut around the meatus. The width of the flap is also half the length of the circumference of the urethra. The next step is the bordering incision around the glans penis before the merging of the incision lines on the ventral surface.
The skin of the trunk of the penis is mobilized according to the principle described above. Then, the fibrous chord is excised until the cavernous bodies are fully expanded. After which they begin to create an official urethra.
On the dorsal surface of the skin flap, a figured island is formed, resembling a two-handed rolling pin. The length of the entire dorsal flap is formed depending on the deficit of the urethral tube. The proximal narrow fragment of the flap, in its width and length, should correspond to the proximal dermal islet of the ventral surface, and the distal narrow fragment of the mobilized skin is created analogously to the distal one on the trunk of the penis. The basic moment in the process of forming flaps remains the exact ratio of the angles of the cut. It is the spatial understanding of the configuration of the future urethra that allows to avoid stenoses in the postoperative period.
Cutaneous islet, formed on a dorsal cutaneous flap, is mobilized with the help of two microsurgical tweezers. Then, at the base of the flap, in a blunt way, a window is created through which the naked cavernous bodies are translated dorsally. The proximal narrow dorsal fragment is stitched with the proximal ventral, onlay continuous continuous intradermal suture to the point indicated in figure 3. The starting points on the dorsal and ventral flaps should coincide. The main fragment of the official urethra is sewn into the tube also continuously. The distal part is formed similarly to the proximal in the mirror image. The urethra is created on the urethral catheter # 8 SN.
The principle of onlay-tube-onlay is used in the undeveloped head of the penis, when the surgeon has doubts about the stage of its closure. In patients with a well developed head, the principle of onlay-tube is used (Fig. 18-96).
To do this, one cutaneous islet is cut out on the ventral surface, bordering the meatus according to the principle described above. On the dorsal surface a flap is created resembling a one-handed rolling pin, the handle facing the base of the trunk of the penis. After the creation of the urethral tube, the distal department of the official urethra de-epithelialize just enough to close the mobilized edges of the head above the urethra. The edges of the head are stitched together by nodular sutures over the created urethra. Naked cavernous bodies are covered with the mobilized skin of the penis.
The method of urethroplasty in children with a posterior form of hypospadias using the urogenital sinus (F-VII)
Often in children with severe forms of hypospadias, the urogenital sinus is detected. Normally, during the formation of the genital organs, the sine is transformed into the prostate and the posterior urethra. However, in 30% of patients with severe forms of hypospadias, sinus is retained. Sinus sizes are variable and can range from 1 to 13 cm, and, the higher the degree of violation of sexual differentiation, the greater the sine. Virtually all patients with a pronounced sinus lack the prostate, and the vas deferens are either completely obliterated or open into the sinus. The inner lining of the urogenital sinus is, as a rule, represented by a urothelium adapted to the effect of urine. Given this circumstance, the idea arose to use urogenital sinus tissue for urethral plastic surgery.
For the first time this idea was implemented in a patient with true hermaphroditism with a karyotype of 46 XY and virile genital organs.
In clinical examination, the child was diagnosed with perineal hypospadias, presence of gonads in the scrotum on the right and gonads in the inguinal canal on the left. During the operation, when revising the inguinal canal to the left, ovotestis, confirmed histologically, is revealed. Mixed gonad, with female and male sex cells. The mixed gonad was removed. The urogenital sinus is isolated, mobilized and rotated distally.
Then the sine is modeled in a tube according to the Mustarde principle up to the foam-scrotal angle. The distal department of the official urethra was formed according to the Hodgson-III method.
Urethral canal surgery using tissue engineering techniques (FVX)
The need to use plastic material, devoid of hair follicles, is dictated by the high frequency of long-term postoperative complications. The growth of the hair in the urethra and the formation of concrements in the lumen of the created urethra create significant problems for the life of the patient and great difficulties for the plastic surgeon.
Currently, more and more widespread in the field of plastic surgery receive technology based on the achievements of tissue engineering. Based on the principles of treating burn patients using allogenic keratinocytes and fibroblasts, the idea of using autologous skin cells for the correction of hypospadias arose.
To this end, the patient is removed from the skin area in a hidden area of 1-3 cm2, immersed in a preservative and delivered to a biological laboratory.
Human keratinocytes are used in the work, since epithelio-mesenchymal relationships do not have specific specificity (Cunha et al., 1983: Hatten et al., 1983). Skin patches of 1x2 cm size are placed in Igla medium containing gentamicin (0 16 mg / ml) or 2000 units / ml benzylpenicillin and 1 mg / ml streptomycin Prepared skin flaps cut into strips 3x10 mm. Washed in a buffer solution, placed in a 0.125% solution of dyspase in DMEM medium and incubated at 4 ° C for 16-20 hours or in a 2% solution of dyspase for 1 hour at 37 ° C. After this, the epidermis is separated from the dermis along the basal membrane The pipetting suspension of epidermal keratinocytes is filtered through a nylon network and pelleted by centrifugation at 800 rpm for 10 minutes Then the supernatant is drained and the pellet is suspended in a culture medium and plated in plastic bottles (Costaf) at a concentration of 200,000 glues The 3 day keratinocytes were then grown in a complete culture medium: DMEM: F12 (2: 1) with 10% fetal bovine serum, 5 μg / ml insulin soluble (human genetically engineered), 10 "6M isoproterenol * 3, 5 μg / ml transferrin. The cells are then grown in DMEM: F12 (2: 1) medium with 5% blood serum, 10 ng / ml epidermal growth factor, insulin and transferrin, and the medium is regularly changed. After the formation of the multilayered layer by the cells, differentiated suprabasal keratinocytes are removed, for which the culture is incubated for three days in DMEM without Ca. After this, the culture of keratinocytes is transferred to the complete medium and, after a day, is passed on to the surface of the living tissue equivalent formed by the fibroblasts encased in the collagen gel.
Preparation of live tissue equivalent
The mesenchymal basis of the transplant collagen gel with fibroblasts is prepared as described previously and poured into Petri dishes with Spongostan sponge. The final polymerization of the gel with the inside of the sponge and fibroblasts is at 37 ° C for 30 min in a CO2 incubator. The following day epidermal keratinocytes are planted on the surface of the dermal equivalent at a concentration of 250,000 cells / ml and cultivated for 3-4 days in a CO2 incubator in a medium of complete composition. One day before transplantation, the live equivalent is transferred to a complete medium without serum.
As a result, a three-dimensional cell structure on a biodegradable matrix is obtained in a few weeks. The dermal equivalent is delivered to the clinic and is formed into the urethra, sewing into the tube or using the onlay principle for urethroplasty. Most often, this technology replace the perineal and scrotal sections of the official urethra, where the threat of hair growth is greatest. The urethral catheter is removed on the 10th day. After 3-6 months, distal urethroplasty is performed by one of the methods described above.
Evaluating the results of operative treatment of hypospadias, it is necessary to pay attention to functional and cosmetic aspects, which allow minimizing the psychological trauma of the patient and optimally adapt it in the society.