CC BY
17
I. ХИРУРГИЯ
UDC 616-006.61
RESULTS OF COMBINED USE OF SKIN AND MUCOSAL MEMBRANE IN MODIFIED OPERATIONS OF THE DEFECTS OF SOFT TISSUES ON HYPOSPADIAS
ABOUT THE AUTHOR
Vagif M. Galandarov - fellow of the Department of plastic surgery, can. med., email: [email protected], mob.0503770000.
Keywords
repair hypospadias, skin and mucous membrane flaps
Galandarov V.M.
Teaching surgery clinic of Azerbaijan Medical University "Galandar" plastic and reconstructive surgery clinic
Abstract
The most teared complication of hypospadias repair is fistula. All techniques that have been developed up to today have aimed in minimizing the fistula rate. Among these, hypospadias repair with vascularised tissues are the procedures after which the fistula development risk is the least. Between 1999 - 2015 among patients with midshaft or distal penile hypospadias and ages ranging between 3 and 5, Duckett technique was applied to nine patients, and four flap technique was applied to seven patients. The operations were all carried out under general anesthesia, and urinary diversion was made in all patients. In 5 patients who were treated with four flaps, the classical Duckett flap (Transversepreputial island flap - A flap) is sutured by 6,0 PDS to the B flap which is prepared from the dorsal urethra. Following this repair, the C flap prepared from the ventrum of the Dartos fascia is placed on the preputialonlay island flap (A), therefore the suture lines are covered with the vascular Dartos fascia flap. Lastly, the advancement flap (D flap) prepared by the dissection of penile skin is sutured to the glans. By these two flaps (C,D) overlap of suture lines is prevented, and the neourethra is covered with vascular flaps (C,D) (Fig. 1). No fistulas occurred in seven patients treated with four flaps. In hypospadias repaired with four flaps, the vascular tissues transferred into the suture line prevented fistula formation and enabled satisfactory aesthetic results
Tepi мен сшемейл1 кабьщты курамдастырылган колдануымен гиппостадиясы кезшде жумсак тшдердщ акаулыктарына модификацияланган реконструктивтч жасалынган отаньщ нэтижелер1
АВТОРТУРАЛЫ
Галандаров Вагиф Магеррам оглы - Пластикакалык; хирургия белшшесшц еылыми к;ызметкер1, м.р.д.,
email: [email protected], т. 0503770000.
Галандаров В.М.
Эз1рбайжан Медицина Университетшщ ок,у-хирургиялык, клиникасы, «Галандар» пластикалык,жэне реконструктивп хирургия клиникасы
Туйш сездер
пипостадияньщ бурынгы калпына келт'/ру, repiHin, флебаныц шырышгы кабыгыныц калпына rnnripinyi
Ацдатпа
Гипостадияны тузешц ец к;ау1пл тур1 фистула болып табылады. Осы кунге дей1н эз1рленген барлык, эдютер фистула денгей/нщ минимизациясына батытталды. Оныц ¡ш/нде тамырланган т1ннщ гипостадиясыныц тузетшунен кей1н фистуланыц дамуынын кдут темендеген турлер1 кездесед/'. 1999 жылдан 2015 жылдыц аралышнда дисталь -ды гипостадия наукдстарыныц арасында жэне жасы 3 пен 5 аралытындаш науцастарга Дюккет эд/с/ цолданылды, терт наукаска терт кесщ1 эд/с/ цолданылды. Барлык; операциялар жалпы наркозбен етюзшд1 жэне барлык, науцастарга зэр жалгамы жасалды. Терт кеанд1 э^амен емделген 5 наукаска классикалык, Дюккет киындысымен жк салынды (келденец препуциалды киынды - А к;иындысы) В к,иындысына дорсальды урпщен алынтан 60 РОБ дей1н. Осы тузетудн артынан С к;иындысы цолданылды, ол енцалтаныц ей/ крбышныц вентрумын толык, кабатты препуциалды циындь^а салады, сондьщан ж1к сызыкгары енцалтаныц ей/ кабьтнын тамырлы киындысымен крпталады. Сонында жаца езгертшген пенист1ц ашылтан терюнщ киындысы (О к;иындысы) юшкене баска т1плед1. Осы ек1 к;иындыныц кдтысуымен ж1к сызыкгары токгатылады жэне неоуретра тамырлы к;иындымен к;апталады. (С,0)(фото 1). 1). Терт киынды эщамен емделген жет1 наукдста ешкдндай фистула болган жок,- Гипоспадиянытерт киынды эд1амен тузетуде васкулярлы т1ндер ж1к сызыкгарына ауысты, фистуланыц пайда болуы токгатылады жэне эстетикалык, нэтижедерд1 терюке шыгарды.
Результаты модифицированных реконструктивных операций дефектов мягких тканей при гипоспадии с комбинированным применением кожи и слизистой оболочки
Галандаров В.М.
Учебно-Хирургическая клиникаАзербайджанского Медицинского Университета, Клиника Пластической и Реконструктивной хирургии «Галандар»
ОБ АВТОРЕ
Галандаров Вагиф Магеррам оглы -сотрудник отделения пластической хирургии, к.м.н., email: [email protected], т. 0503770000.
Аннотация
Наиболее опасным осложнением исправления гипоспадии является фистула. Все методы, которые были разработаны до сегодняшнего дня, были направлены на минимизацию уровня фистулы. Среди них, исправление гипоспадии с васкуляризированными тканями процедура, после которой уменьшается риск развития фистулы. С 1999 по 2015гг среди пациентов с дистальной гиспоспадией и у пациентов в возрасте между 3 и 5 г девяти пациентам применялся метод Дюкетта, и семи пациентам применялся метод четырёх лоскутов. Все операция проводилась под общим наркозом и всем пациентам было сделано отведение мочи. У 5 пациентов, которых лечили методом 4 лоскутов наложен шов классическим лоскутом Дюкетта (поперечный препуциальный лоскут - лоскут А) до лоскута В от 60 PDS, полученного из дорсальной уретры. Следом за этим исправлением, лоскут С, получаемой из вентрума мясистой оболочки мошонки помещают на полнослойный препуциальный лоскут, поэтому линии швов покрываются васкулярным лоскутом мясистой оболочки мошонки. В конце, новый изменённый лоскут (D лоскут), полученный из рассечения кожи пениса пришивается к головке. Посредством этих двух лоскутов (C,D) предотвращается линии швов и неоуретра покрывается васкулярным лоскутом. (C,D) (фото 1). У семи пациентов, которых лечили методом 4 лоскутов не происходило никакой фистулы. В исправлении гипоспадии четырьмя лоскутами васкулярные ткани перемещены на линию шва, предотвращено появление фистулы и получены исчерпывающие эстетические результаты.
Ключевые слова
Восстановление гипоспадии, кожи и слизистой оболочки флебы
In the recent years, the use of techniques that were applied after better understanding of penile skin structure, vascularization of the penis and the preputial layers, and the anatomic formation have enabled fewer postoperative complications' The combined application of many techniques have been improved and is currently being used with success. Repair by using vascular pedicle onlay island flap and transverse preputial island flap after the orthoplasty dorsal tucks procedure has successful outcomes [17,21,23]. Despite satisfactory early and late postoperative results, risk of fistula persists. By the modification we apply, we believe that an even further decrease in fistula risk is enabled. This is proven by the successful results that we have obtained in our clinical practice.
In the repair of distal penile and midshaft hypospadias using onlay island and transverse preputial island flaps, we first perform an orthoplasty dorsal tucks. This is followed by the advancement of penile skin in a circular manner after rotation, and back cut which we made without disrupting the Dartos fascia on the ventral aspect. Excess prepuce is excised. This circular advancement of penile skin onto the newly repaired urethra on the ventral aspect of the penis reduces fistula rate, a fact which was observed in our clinical cases.
Combined use of the transposed vascularised penile fascia and circular penile skin advancement using onlay transverse preputial island flap in the repair of distal penile and midshaft hypospadias has enabled a decrease in fistula risk.
Patient and methods
Between 1996- 2015 using onlay island and transverse preputial island flap, urethral repair was carried out in 16 patients with distal penile and midshaft hypospadias. First, urinary diversion was made by Cystofix placement. In the first 9 cases, after determination of the presence of chordee [15], transverse preputial island flap (A-flap) was prepared. After this, the flap which was going to form the dorsal urethra (B flap) was prepared. Following orthoplasty dorsal tucks [22], onlay placement of the transverse preputial island flap onto the surface of B flap was carried out. This onlay flap was sutured to the anterior side of the B flap using 6,0 PDS sutures and the new neourethra was formed around the silicone urinary catheter. The penile skin was adapted and covered over this area. Operative principles in the literature were applied to all of the cases. Despite meticulous attention to all preoperative and postperative principles, fistula occurred in 3 of the patients. 4 months later, fistula repair was made.
To minimize the risk of fistula in the patients, urethral repair with the method discussed above was carried out in 7 patients with distal penile and midshaft hypospadias. A back cut was made on the Dartos fascia on the ventrum of the penis, thereby bringing vascularised tissue on the suture line where urethroplasty was made. By this technique, we were able to increase the tissue perfusion in this region and the suture line was buried under an ad-
Figure 1.
Schema describing the fourflaps: A:Trans-versepreputial island flap, B: Flap prepared from the urethral plate and going to make the dorsal urethra, C: Flap prepared from the ventral side ofthe Dartos fascia, D:Circularad-vancementflap, prepared by dissection of penile skin up to the scrotum
Figure 2.
Case with distal penile hypospadias, viewof the fourflaps after preparation, onlaysuturing ofthe transverse preputial island flap onto the C flap prepared from the urethral plate, the newly formed neourethrathe C flap (Dartos fascia flap) brought onto the newly formed neourethra. Suturing the circular advancement flap of penile skin to the glans, urination postoperatively, urination 1.5 years potsop
ditional vascularised tissue. We believed that the C-flap, which underwent a back cut would make a major contribution in minimizing the fistula risk (Fig.1-2).
In hypospadias repair, the prepuce skin forms a suture line on the ventrum of the penis where urethroplasty is made. This in turn increases the risk of fistula. One of the important procedures in fistula prevention in distal penile and midshaft hypospadias is the closure of penis or prepuce skin during the last step in a way which causes no suture line on the ventrum. The use of 0.5-1.0 mm prepuce skin on the ventrum results in a suture line and consequently this suture line increases the fis-
tula formation in that region. Therefore, to prevent vertical suture line formation, the use of prepuce skin on the ventrum should be avoided. In this procedure, where we no longer have a vertical suture line, the prepuce is cut in a circular manner as in circumcision, and the remaining skin of the penis is dissected to the scrotum. This dissection allows 0.5-1.0 cm of skin to be taken from the scrotum and enables circular advancement towards the head of the penis [3,8,16]. The D-flap which we make circular advancement forms a single circular suture line close tothe glans ofthe penis (Fig.1-2)
Results
No fistula was observed in 7 patients who underwent the procedure discussed above. Of the 9 cases which we did not use this method, 3 developed fistula. The fact that the new method which we apply in distal penile and midshaft hypospadias significantly reduces fistula risk is therefore proven
Discussion
As we know from the literature, infection risk in the suture lines around the new repaired neourethra has always been one of the major factors in fistula formation. The Dartos fascia [2,9,13,14] - C flap rotation which we carry onto the suture line via backcut and the simultaneous circular advancement of penile skin, bury the suture lines and increase regional blood flow . The infection risk is decreased in the regions where blood perfusion is good. When rotation by using backcut is applied to the Dartos fascia that is located on the ventrum of the penis, 4X loupe magnification is needed in order to prevent disruption of the circulation. The onlay placement of transverse preputial island flap-A onto the B flap forms a suture line on the neourethra. The double layer formation of the C and D flaps which are placed on these suture lines significantly decreases fistula risk.
In our applications during our clinical study, the combined use of the C flap prepared from the Dartos fascia and the D flap formed from the circular advancement of penile skin in the repair of neourethra which was formed by the classical Duckett technique, gave functionally and cosmetically positive results. We believe that in distal and midshaft hypospadias the combined use of four flaps, the transverse preputial island flap A, the B flap that is going to form the dorsal urethral mucosa, the C flap prepared from the Dartos fascia and the D flap formed by the circular advancement of penile skin will significantly decrease fistula risk. Despite its success in midshaft and distal penile hypospadias repair, the use of this technique in other localisations of hypospadias is not recommended.
References
1. Hinman F.Jr. Structure and Function of the Penis and Male Urethra, Atlas of Urosurgical Anatomy, Philadelphia, W.B. Saunders Company. 1993. P. 430-436.
2. Hinman F.Jr. Repair of Urethral Strictures - Island Patch Flap, Atlas of Urosilgical Anatomy, Philadelphia, W.B. Saunders Company. 1993. P. 467.
3. Rochet B. Nouveau procédé pour refaire le canal peniendansl"hypospadias .Gaz.Hebd. Med Chir. 4: 673, 1899.
4. Wehrbein H.L. Hypospadias. J. Urol. 50:335, 1943.
5. Cassen P.R., Bonnano P.C., Converse J.M. Penile Skin Replacement :lndications and Techniques. In J.T. Heusten (Ed), Transactions of the Fifth International Congress of Plastic and Reconstructive Surg. Melbourne , Australia: Butterworth, 1971.
6. Arconti J.S., Goodvin W.E. Use of scrotal skin to cover wound defects in the groin and public area. J Urol .75: 292, 1956.
7. Horton C.J. McCraw J.B., Devine C.J., Devine P.C. Secondary reconstruction of the genital area. Urol. Clin. North Am. 4:133, 1977.
8. Robinson D.W., Stephenson K.L, Padgett E.G. Loss of coverage of the penis, scrotum, and uretra. Plast. Reconstr. Surg. 1: 58, 1946.
9. DesPrez L., Keihn C.L. One-stage repair of hy-posdaias by Island flap technique. Plast.Re-constr.Surg. 28: 154, 1961.
10. Horton C.E., Devine C.J., Graham J.K. Fistulas of the penile urethra. Plast.Reconstr.Surg. 66: 407, 1980.
11. Horton C.E., Urethral Fistulas. In C.E. Hortan (Ed), Plastic and Reconstructive Surgery of the Genital Area. Boston: Little, Brown, 1973. P. 402.
12. Walker D. Outpatient repair of urethral fistulae. Urol .Clin. North Am. 8: 582, 1981.
13. Orandi A. One-stage urethroplasty. Br. J. Urol. 40: 717, 1968.
14. Quartey J.K.M. One-strage penile / preputial cutaneous Island flap urethroplasty. J. Urol. 129: 284, 1983.
15. Horton C.E., Devine C.J. Chordee without Hys-pospadias. In C. E. Horton (Ed), Plastic and Reconstructive Surgery of the Cenital Area. Boston: Little Brown, 1973. P. 384.
16. Bruner J. Traumatic avulsion of the skin of the external genitalia. Plast.Reconst.Surg. 6: 334, 1950.
17. Byars L.T. Functional restoration of hypospadias. Surg. Gynecol. Obstet. 92: 147, 1951.
18. Hodgson N.B. A one-stage hypospadias repair. J.Urol. 104:281, 1970.
19. Duckett J.W. Transverse preputial island flap technique for repair of severe hypospadias. Urol. Clin. North A. 7:423,1980.
20. Hinman F.Jr. Structure and function of the penis and male urethra-preputial blood supply, Atlas of Urosurgical Anatomy, Philadelphia, W.B. Saunders Company, 1993, p. 437.
21. Cizmeci O., Kocak T., Gorgun B., Erdogan T., Preputial and penopreputial vascularized flaps for urethral reconstruction in hypospadias. Turkish Journal of Urology, Vol. 20, 1,p 127131, 1994.
22. Duckett J.W. The island flap technique for hypospadias repair. Urol. Clin.N. Amer., 8:501, 1981.
23. James R. Craig, Chad Wallis, et al. Management of adults with prior failed hypospadias surgery // Trans Andr. Urol, 2014, Vol 3, No 2.
