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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5514_Библиотеки_им_академика_М_И_Перельмана.pdf
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Fig. 9.6 (a) Muscle of urogenital diaphragm in bladder exstrophy as seen during exposure via
scrotoperineal approach: (1) perineal body, (2) ischiocavernosus muscle, (3) bulbospongiosus
muscle, (4) corpora cavernosa, (5) triangular space containing sphincteric branch of perineal
nerve, (6) supercial transverse perinei muscle, (7) intersymphyseal band, (8) ischiopubic ramus,
and (9) glans. (b) Muscle of urogenital diaphragm in bladder exstrophy as seen in volume-rendered
CT imaging: (1) perineal body, (2) ischiocavernosus muscle, (3) bulbospongiosus muscle, (4) corpora cavernosa, (5) triangular space containing sphincteric branch of perineal nerve, (6) supercial
transverse perinei muscle, (7) intersymphyseal band, (8) ischiopubic ramus, (9) glans, and (10)
bladder plate
S. N. Kureel et al.
perineal body is present in the center of the base of the urogenital diaphragm. The
corpora cavernosa are attached to ischiopubic rami, and the root of the corporal
body is covered with ischiocavernosus muscle on both sides. Between the corpora
cavernosa, the corpus spongiosum in the midline supports the dorsal urethral plate.
Distally the corpus spongiosum is attached to the glans, while the proximal part is
expanded as a bulb. The proximal-most part of corpus spongiosum is covered with
bulbospongiosus muscle, which is attached to the perineal body (Fig.9.6a, b). The
bulbospongiosus muscle is continuous with the striated urethral sphincter bers,
which lay open on the cranial aspect of the bulbospongiosus muscle, anking the
urethral plate at the verumontanum. Supercial transverse perinei muscles at the
base of the urogenital diaphragm are attached to the perineal body in the midline
and laterally to the ischiopubic ramus near the ischial tuberosity (Fig.9.6b). The
potential triangular space between the medial surface of the ischiocavernosus muscle, the lateral aspect of the bulbospongiosus muscle, and the superior border of the
transverse perinei muscle is somewhat accentuated in bladder exstrophy (Fig.9.6a,
9 Scrotoperineal Approach toBladder Exstrophy Repair
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Fig. 9.7 Schematic diagram of panoramic view of undersurface of urogenital diaphragm in classic male exstrophy bladder showing muscles of urogenital diaphragm: (1) bulbospongiosus muscles, (2) ischiocavernosus muscles, and (3) supercial transverse perinei muscle, all attached to (4)
the central perineal body. (5) Triangular space between (1) bulbospongiosus, (2) ischiocavernosus,
and (3) supercial transverse perineal muscle containing (6) branches of perineal artery and nerves,
including sphincteric branches. On the right side, proximal (7) corpora cavernosa, (2) ischiocavernosus muscle, and most of (3) supercial transverse perinei muscle, and on the left side middle part
of (7) corpora cavernosa are shown as removed to show (8) deep artery of penis and course of (9)
dorsal penile artery and nerves along the lateral aspect of (7) corpora after leaving the inner edge
of (10) ischiopubic ramus. Deep to the perineal membrane shadow of (11) deep transverse perinei.
(12) External anal sphincter, (13) glans, and (14) bladder plate
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b). It is in this space that the sphincteric branches of the perineal nerve and artery
course toward the bulbospongiosus muscle and the external urethral sphincter. The
course of this nerve and vessel is parallel to the medial aspect of the ischiocavernosus muscle (Fig.9.7). Therefore, by maintaining the plane of dissection close to the
medial surface of the ischiocavernosus muscle, injury to this nerve and vessel can
be avoided. This is the “safe plane of dissection” for corporal-urethral separation in
this region. Another important anatomical detail to remember is that the pudendal
vessels and nerve branch out as dorsal penile vessels and nerve after exiting Alcock’s
canal. They form the neurovascular bundle on the dorsolateral aspect of the distal
part of the corpora cavernosa. Proximally, the neurovascular bundle runs along the
inner edge of the ischiopubic ramus and then courses into Alcock’s canal (Fig.9.7).
The surgical signicance of this detail is that by entering the subperiosteal plane
along the outer edge of the ischiopubic ramus for radical corporal detachment and
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Fig. 9.8 The nerve locator
probe is used to locate the
sphincteric branch of the
perineal nerve and other
nerves
S. N. Kureel et al.
maintaining this subperiosteal plane onto the medial aspect of ischiopubic ramus,
the preservation of neurovascular bundle is almost guaranteed despite radical corporal detachment down and even beyond its root. Additionally, the cavernous nerve is
also preserved. All nerves can be identied using a nerve locator (Fig.9.8).
Anatomy ofFascial Planes andVessels inEpispadiac Penis
The anatomy of fascial planes and vessels and their surgical signicance in epispadias have been published earlier by us [13]. The anatomy of fascial planes and
vessels is shown in the schematic diagram (Fig.9.9). The urethral plate lies on the
dorsal side and continues to the tip between both the hemi glans. On the ventral
side, the penile skin on either side of the median raphe runs up to the scrotal
rugosities proximally and to the outer preputial skin distally. From the preputial
edge, the inner preputial skin continues to the subcoronal sulcus, with a midline
frenulum (Fig.9.10). Penile skin and dartos are supplied by a pair of axial vessels
from external pudendal vessels on both sides. The inner preputial skin has a double blood supply from preputial dartos vessels and from ultrane branches of
dorsal penile vessels, which branch out just before it enters the substance of the
glans (Figs.9.9, 9.11, and 9.12). A layer of loose areolar tissue lies between the
penile dartos and the Buck’s fascia over the corpora. The corpora cavernosa are
encased in a double- layered tunica albuginea, whose bers are oriented longitudinally in the outer layer and circularly in the inner layer. The outer longitudinal
layer of the tunica albuginea of the corpora cavernosa is somewhat decient medially onto the surface facing and anking the wedge of corpus spongiosum. The
neurovascular bundle runs parallel and lateral to the urethral plate on the dorsolateral aspect of the tunica albuginea and enters the glans substance distally. The
corpus spongiosum is encased in a single ultrathin layer of tunica albuginea. The
Buck’s fascia encasing the corpora cavernosa splits to envelop the neurovascular
bundle dorsolaterally and fuses again into one layer medial to the neurovascular
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9 Scrotoperineal Approach toBladder Exstrophy Repair
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Fig. 9.9 Schematic diagram showing arrangement of fascial planes and course of blood vessels and
collateral branches in epispadiac penis. (1) Inner preputial skin split off the (2) outer preputial skindartos along with ventral penile skin-dartos, degloved, and bifurcated as two lateral aps. (3) Axial
vessels from (4) external pudendal vessels seen running in (5) dartos fascia of both halves of ventral
preputial skin. The middle segment of the shaft of the epispadiac penis is shown as removed to show
details of the anatomic arrangement of the fascial plane. (6) Skin and dartos at proximal shaft penis,
(7) Buck’s fascia surrounding corpora, blending with ultrathin tunica albuginea of corpus spongiosum
and splitting to envelop (8) dorsal penile vessels and nerves, (9) branches from dorsal penile vessels
perforating into dartos and communicating with branches of axial vessels, (10) at coronal sulcus, terminal branches of dorsal penile artery entering glans give branch to prepuce and communicate with
terminal branches of axial vessels of dartos, (11) tunica albuginea—double layer on the lateral side and
single layer on the medial side, (12) dorsal open urethral plate (middle of urethral plate schematically
removed to show anatomic layers), (13) glans, (14) wedge-shaped corpus spongiosum, and (15) terminal branches of dorsal penile vessels lateral to urethral plate deep to Buck’s fascia
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bundle. Medially it fuses with the ultrathin tunica albuginea of the corpus spongiosum to form one layer (Fig.9.9). On the dorsal side, there is a layer of lamina
propria underneath the urethral plate. This lamina propria and urethral plate
receive their blood supply through the wedge of corpus spongiosum (Fig.9.9).
The relevant points of surgical signicance are that:
(i) since inner preputial skin has a dual blood supply, it remains viable even when
split off the outer preputial skin-dartos and is useful in the skin cover [7].
(ii) The axial blood supply of the penile skin-dartos complex ensures the viability
of both halves when it is bifurcated in the midline to be used for penile skin
cover [7] (Fig.9.11).
(iii) Buck’s fascia can be disrupted in the margin between the neurovascular bundle
and the urethral plate. Working in a subfascial plane on the tunica albuginea,
corporal-urethral separation can be performed without compromising the vascularity of the corpus spongiosum [13].
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Fig. 9.10 Frenulum
between the ventral
midpoint of the corona and
inner preputial mucosa
Fig. 9.11 Axial vessels
(1) seen in the penile skin
dartos complex on each
side of the midline
S. N. Kureel et al.
9 Scrotoperineal Approach toBladder Exstrophy Repair
Fig. 9.12 Ultrane
straight vessels (1)
supplying the inner
preputial mucosa skin
coming from (2) dorsal
penile vessels
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Relevant Anatomical Details ofOpen Bladder Plate
Since lower abdominal mesenchymal structures are lateralized in bladder exstrophy, pubic bone diastasis is present with variable interpubic distance. Seeking
attachment to pubic crest, rectus abdominis muscles diverge, leaving a midline
gap of variable size. The wide and stretched linea alba bifurcates to follow the
medial edge of rectus abdominis down to the pubic tubercle and merges with the
anterior rectus sheath laterally (Fig.9.13). The posterior rectus sheath is present
only up to the arcuate line. Beyond this level, the extraperitoneal space behind
the posterior bladder wall contains loose areolar tissue, fat, and sometimes aberrant branches of the inferior epigastric vessels (Fig.9.14). The edge of the bladder plate mucosa is attached to the skin of the abdominal wall, while the detrusor
underneath the mucosa is attached to the bifurcated linea alba at the medial edge
of the rectus muscle. Intersymphyseal bands are present on either side between
the open bladder neck and the pubic bone laterally. Caudally, the intersymphyseal band extends up to the anterior edge of the levator muscle and lies in intimate contact with the root of the corpora cavernosa and its neurovascular bundle
(Fig.9.13). The autonomic perivesical plexus and perivesical fascia lie on the
posterior aspect of the bladder plate. The obliterated umbilical arteries course on
the posterior aspect of the bladder plate toward the midline (Fig.9.15). Sometimes,
the superior vesical artery may arise from the root of the obliterated umbilical
artery. The blood supply to the detrusor comes from the inferior vesical artery, a
branch of the anterior/posterior division of the internal iliac artery (Fig.9.16).
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Fig. 9.13 Schematic
diagram showing
anatomical facts of open
bladder neck (1) open
bladder plate, (2)
verumontanum, (3) open
glans, (4) neurovascular
bundle on corpora
cavernosa, (5)
bulbospongiosus muscle of
urogenital diaphragm, (6)
ischiocavernosus muscle,
(7) sphincteric branch of
perineal nerve, (8)
intersymphyseal band, (9)
rectus muscle, (10)
stretched linea alba, (11)
pubic bone, and (12)
ischiopubic ramus
Fig. 9.14 Operative
picture showing (1) arcuate
line, (2) extraperitoneal fat
below, (3) bladder plate
margin, (4) stretched linea
alba, (5) rectus muscle, (6)
posterior rectus sheath, and
(7) roller gauze placed in
extraperitoneal space
S. N. Kureel et al.
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9 Scrotoperineal Approach toBladder Exstrophy Repair
Fig. 9.15 Mobilized
bladder plate showing (1)
obliterated umbilical artery
on the posterior aspect of
corpora and (2) fold of
peritoneum
Fig. 9.16 CT angiogram
MIP image showing (1)
inferior vesical artery and
(2) pudendal artery
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Technical Details ofBladder Exstrophy Reconstruction Using
Midline Scrotoperineal Approach
Preoperative Evaluation andPreparation
A baseline renal nuclear scan to record preoperative renal anomalies, renal function, and
absence of renal scarring is done for comparison on follow-up after surgery (Fig.9.17).
A plain CT of the pelvis with a volume-rendered three-dimensional image of the
CT pelvis is obtained to evaluate the pelvic conguration in anterior, superior, perineal, and oblique views (Fig.9.18a–d). This helps in planning the osteotomy.
At our center, surgical repair is undertaken at 10–12weeks of age after a reliable
evaluation of the upper tract by nuclear study is obtained after 6weeks of age.
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Fig. 9.17 Preoperative
radionuclear scan for the
upper tract showing
ectopic location of the left
kidney
S. N. Kureel et al.
Fig. 9.18 Preoperative CT pelvis volume rendered image. (a) Anterior view, (b) posterior view,
(c) superior view, and (d) perineal view showing complete perineal conguration
9 Scrotoperineal Approach toBladder Exstrophy Repair
A mild laxative 12hours prior to surgery and a digital rectal examination before
shifting the patient into the operating room ensure an empty rectum at the time of
surgery.
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Anesthesia
General anesthesia with relaxant is administered with lines for measurement of
blood pressure, central venous pressure, probes for temperature maintenance with
ETCO2 monitoring with continuous ECG monitoring. An epidural catheter is placed
for postoperative analgesia.
Patient Positioning andDraping
The patient is placed in a supine position. The thighs up to the knee joints are draped
in sterile leggings, and the rectum is packed with sterile roller gauze. The sterile
drapes are anchored in the midline to the base of the urogenital triangle.
Incision
At the level of the transtubercular line, a midline trapezoid ap is marked for umbilicoplasty [8] (Fig.9.19a). Incision lines are drawn along the ventral midline from
the tip of the trapezoid ap to the bladder plate and from here along the margin of
the bladder plate up to the bladder neck (Fig.9.19a, b). From the bladder neck, incision lines are drawn along the margin of the urethral plate up to the tip of the glans
on both sides (Fig.9.19b).
Stay sutures are placed lateral to the margin of the urethral plate at the tip of the
glans. Feeding tubes are placed in ureteric orices and connected to a reservoir for
urine output measurement.
The edge of the prepuce is marked and held with stay sutures (Fig.9.19c). The
median raphe of scrotum from the base of the urogenital triangle and the median
raphe of penile skin up to the edge of the prepuce are also marked (Fig.9.19d).
Bladder Plate Mobilization
Using ne needle-tip cautery, the umbilicoplasty ap is raised. A plane is developed
in the subcutaneous plane supercial to the anterior rectus sheath by passing long
artery forceps down to the pubic bone on both sides (Fig.9.20a, b). Vesicocutaneous
continuity is disrupted with the help of ne needle-tip cautery up to the bladder neck
and root of the penis (Fig.9.20c).
Near the root of the penis, the penile dartos is carefully dissected off to expose
the root of the corpora (Fig.9.20d).