URETHROPLASTY (Greek urethra an urethra + plasti-kyo sculpture, plastics) — the surgery made for the purpose of recovery of an urethra at its anatomic defects of the acquired or inborn character bringing to its impassability or disturbance by ugly creatures ki.
At. apply at fistulas (see), strictures (see) and obliterations of an urethra (urethra) of various origin, at malformations — a hypospadias (see), epispadiya (see), at the final stage of operation of recovery of a penis (see the Phalloplasty.).
As contraindication to operation serve the serious general condition, existence of suppurative focuses in an organism, inflammatory diseases of skin.
At a preparation for surgery special attention is paid by sanitation of uric ways. The patient with the broken urination in the presurgical period impose suprapubic fistula (see Cystostomy), appoint antibacterial pharmaceuticals (see. Antimicrobic means), in the presence of uric zatek (see) and abscesses (see) they are opened.
In most cases At. represents the difficult multi-stage surgery which is carried out in specialized the Urals. departments. Operation is made, as a rule, under anesthetic. Small operative measures at the intermediate stages At., napr, cutting off of a leg of a bucket-handle graft, is admissible to carry out under local anesthesia.
There are several types At.: closing of defect of a wall of an urethra by means of a seam or a rag of fabric, a resection of the narrowed site of an urethra with imposing of an anastomosis the end in the end or substitution of the resected site a transplant, creation of missing department of an urethra by means of various ways of plastics. As material for plastics most often serve skin of a penis and a scrotum, sometimes — skin of a stomach, a hip (see. Skin plastics); in rare instances make plastics tissues of a bladder. Skin is used in the form of rags on a leg, apply free plastics less often. Offers to apply as material for At. other bodies and educations (an artery, a vein, an ureter, a worm-shaped shoot, etc.) did not gain distribution.
Choice of a method U. in each case is defined by the nature of pathology and a condition of the fabrics intended for plastics. During the planning of operation consider localization of defeat, its extent, existence of hems, extent of deformation of a penis, a reserve of plastic material. At the lack of skin connected with shortening and a chordee, the first stage of operation is its straightening and creation of a stock of skin by plastics counter triangular rags by Savchenko's method (see the Hypospadias). At all types At. drainage of a bladder by means of cystostomy is obligatory (see); the urethra is created on the catheter entered into a bladder.
Methods of closing of urethral fistulas include sewing up of defect of a wall and plastics the piece of leather found in close proximity to fistula. By Gyuyon's method the plastics is carried out in two options. By the first option over fistula and under it do cross sections, to-rye connect midsection through fistula. Cicatricial fabric is excised together with fistula, side rags of skin will mobilize. At bottom edge of a wound find a skin rag, the basis to fistula, wrap it and close an epidermal surface a fistular opening, bring surplus of a rag under skin of the upper edge of a wound and fix seams to skin. Stack on a wound surface of the main rag and sew the mobilized side rags, and pull together defect of skin and take in. By the second option quadrangular rags of skin find from fistula on each side; after its excision one of rags is wrapped epidermis inside and close them a fistular opening, the second is pulled over the first, closing a wound surface of a skin rag and defect of skin. By the same principle carry out plastics by Koltsov's method, in Krom use skin of a scrotum.
At extensive defects in a spongy part of an urethra apply various options of skin plastics rags on a leg, the migrating bucket-handle graft from skin of a scrotum, a prepuce, a stomach, a hip etc. The simplest is closing of defect of an urethra with skin of a scrotum without its movement. For this purpose cuts of skin make on both parties of defect and continue them on a scrotum; penis wounds and a scrotum combine and sew internal, then their outer edges in the beginning. At good engraftment of skin in 10 — 12 days two cuts made on 2 cm otstupya from a hem release a penis from a scrotum and take in a skin wound.
At urethrovaginal and uretrorektalny fistulas after dissociation and separate sewing up of fistular defects in order to avoid a recurrence displace pieces of the fistular course, adjacent to bodies, on different levels; at division of uretrorektalny fistula make plastics a muscular rag (see. Urinogenital fistulas).
At strictures or an obliteration of an urethra of small extent after excision of hems and a resection of the narrowed site within healthy fabrics impose an anastomosis between
distal and proximal pieces of an urethra the end in the end by Klien's method — Holtsova, and also use the technique of a resection of an urethra with imposing of an anastomosis developed by V. I. Rusakov (see the Urethra). At big to a diastase of the resected ends of an urethra apply Solovov's method: in cicatricial fabric create the channel in the direction to a proximal piece of an urethra, through to-ry extend a distal piece by means of the threads attached to it or a rubber tube, pull together with proximal and invaginate in it; threads remove through suprapubic fistula and fix to skin of a stomach.
At strictures of an urethra of big extent apply several methods of plastics. In a spongy part of an urethra carry out Mikhaylovsky's operation: skin of a penis make cuts a circular section at a coronal furrow, otseparovyvat and shift as a stocking; the urethra in the field of a stricture is cut longwise, excise hems, through the central end enter a catheter into a bladder; on a penis pull otsepa-rovanny skin and hem it in the area of a section. The regenerating epithelium of an urethra acquires a catheter in the form of a tube. At this localization of a stricture apply also plastics skin of a scrotum (see fig. 13 to St. Urethra, t. 15, Art. 531). For recovery of back department of an urethra use tubular rags from skin of an inner surface of a hip or tissue of a bladder according to Froome-will throw. After a resection of the narrowed site create a tubular skin rag on a leg epidermis inside; the free end of a tube is sewed with a proximal piece of an urethra. In 3 — 4 weeks the rag is cut and sew the end of a tube with a distal piece of an urethra. At damage or destruction patol. process of prostatic and webby parts of an urethra make operation on Solovov or plastics tissues of a bladder. From a front wall of a bladder find two rags and create of them a tube, to-ruyu connect to the distal end of the resected urethra. At strictures of a webby part of an urethra of big extent use also Ioganson's method. The method consists in substitution of walls to and mocheis and a mustache of the telny channel a piece of leather of a scrotum: an urethra in the field of a stricture cut longwise; the rectangular rag found from skin of a scrotum is hemmed to edges of defect of an urethra epidermis inside. After engraftment of a rag his leg is cut and sew up a wound of a scrotum.
At. at a hypospadias (see) aims at creation of the absent department of an urethra. The easy form of a hypospadias when the outside opening of an urethra is located in the field of a balanus, usually does not demand correction, except for cases of an urethrostenosis or a chordee. The majority of methods of plastics at this form of a hypospadias consists in mobilization of the distal end of an urethra, its removal on a top golovkrg a penis through a section of skin or via the hypodermic tunnel and fixings by seams to skin of a balanus.
The greatest number of methods of plastics is offered at a hypospadias of a spongy part of an urethra. At the heart of these methods and their modifications formation of a missing part of an urethra from skin of a penis or a scrotum using various ways of closing of the formed skin defect lies.
By Beven's method on a lower surface of a penis, around a gipospadichesky opening, find a skin rag of an ellipse form, otseparovyvat its proximal part from the subject fabrics, impose on distal epidermis inside and create an urethra on a catheter, sewing side edges of a rag. The wound of a penis is taken in, pulling together its edges over the created urethra. The considerable tension of skin in these cases is fraught with danger of discrepancy of seams. Therefore the skin wound is closed more often by means of a rag, napr, from an internal leaf of a prepuce (Ombredann's operation). The method of an uretro-ilastika across Dyupley, applicable was widely adopted at any form of a hypospadias (see). The rectangular rag is found from a gipospadichesky opening to a balanus; will mobilize and sew side edges of a rag on a catheter, sew up a skin wound. An essential lack of this method is the tension of edges of a wound. Dyupley's method provides strengthening of a wall of an urethra by the shift of the line of seams due to mobilization of one of side rags in Savchenko's modifications (see fig. 4 to St. Hypospadias, t. 5, Art. 516). According to Cecil — Kalpa the urethra created by Dyupley's method is temporarily immersed in a section of skin of a scrotum with the subsequent release (see fig. 3 to St. Hypospadias, t. 5, Art. 515); on Verbeyna as material for closing of a wound of a penis serves previously the sfor. - a mirovanny bucket-handle graft from skin of a scrotum.
For plastics of a spongy part of an urethra it is also offered to use various options of the tubular rags created from skin of a prepuce (Kulakov's operation, Davis — Tirmanna), scrotums (Ro-she's operations, Yefimova), hips (operations to Gu-synina, Nova-Zhosserana), a stomach (Shupik's operation), etc. Common fault of tubular rags, especially at free plastics — insufficient blood supply and the complications connected with it — wrinkling, a necrosis and sequestration of a transplant or its part with formation of fistulas. Besides, tubular rags are a little effective at big defects of an urethra.
The optimum functional result is achieved during the use of rags on the wide feeding basis, a cut provides preservation biol. properties of fabrics. One of such methods is the plastics on Landerera applied at chlenomoshonochny localization of a hypospadias. In the beginning two parallel cuts from a coronal furrow to the basis of a penis proceeding on the same distance on a front surface of a scrotum find a continuous skin rag. Slightly will mobilize side edges of a rag, compare the wound surfaces of a penis and a scrotum, sew the inner and outer edges of wounds, creating an urethra and at the same time fixing a penis to a scrotum. In 6 — 8 weeks the penis is separated from a scrotum and take in the formed wound noose sutures. In case of an excessive tension of skin at sewing up of a chlenomoshonochny corner of a wound resort to cutting out of counter triangular rags from skin of a scrotum. This method in Rusakov's modification thanks to connection of slits on a penis and a scrotum additional cross sections allows to carry out plastics at various localization of defeat in limits of a spongy part of an urethra. By means of the additional meeting cuts on a balanus move an outside opening of a newly created urethra on a top go-
are DEXTEROUS (see fig. 13 and 14 to St. Urethra, t. 15, Art. 531' 532).
At an epispadiya (see) At. make in case of splitting of an upper wall of an urethra throughout a penis and a full epispadiya with splitting of a sphincter of a bladder and an incontience of urine. At an epispadiya of a penis make plastics with use of skin of a penis, a scrotum, front abdominal wall. By Dyupley's method defect of a wall of an urethra is closed by sewing together of two skin rags found on both sides along an urethral trench; again formed urethra is displaced from top to bottom and have between cavernous bodies. At plastics but to Nelaton defect is closed a rectangular skin rag from a front abdominal wall with the basis at an epispa-dichesky opening. During the splitting of a sphincter of a bladder and an incontience of urine carry out Young's operation consisting in elimination of a front bezmytpechny segment of a bladder and narrowing of his neck.
The catheter entered into an urethra during operation is deleted on 4 — the 5th days after operation; on 12 — the 13th days make control bougieurage (see) urethra, on 15 — the 16th days delete a drainage tube from a bladder. Suprapubic fistula is closed independently in 3 — 5 days after removal of a drainage tube. As a rule, within the first week of the postoperative period sick appoint antibiotics. Apply sedative pharmaceuticals to suppression of erections. In most cases as a result of operation it is possible to recover function
of an urethra.
In the postoperative period such complications as discrepancy of seams in the field of an anastomosis and a skin wound, uric infiltration of fabrics, suppuration of a wound, a necrosis of a rag with formation of fistulas are possible. At emergence of complications make repeated operative measures. The most important measures of prevention of complications are the right choice of a method of an urethroplasty, thorough preoperative training, drainage (see) a bladder, use of an inert suture material (see).
See also Urethra.
Bibliography: V. I. hares and To r the expert at l and B. V N. Recovery operations at big defects of an urethra at men, Tashkent, 1968;
Savchen co of H. E. Gipospadiya and hermaphroditism, Minsk, 1974; H at x r and e and to about D. P. and L yu l to about A. V. The atlas of operations on bodies of urinogenital system, M., 1972; Urologic surgery, ed. by J. F. Glenn, N. Y. a. o., 1975. C.H. Tereshchenko.