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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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S. N. Kureel et al.
c d
Fig. 9.19 (a) Incision plan including incision for trapezoid umbilicoplasty ap at the level of
transtubercular line, incision along the bladder plate, and incision along the urethral plate; (b)
Close-up view of incision line at proximal urethra and the glans. (c) Incision line along the preputial edge. (d) Scrotoperineal view showing the incision line along the median raphe
Along the medial edge of the rectus abdominis muscle, the continuity of anterior
rectus sheath to linea alba is disrupted down to the pubic tubercle to expose the
posterior rectus sheath on both sides (Fig.9.21a).
Below the arcuate line, where extraperitoneal fat and loose areolar tissue are present, an extraperitoneal plane is easily created with the help of a roller gauze (Fig.9.21b).
This plane is maintained, keeping the obliterated umbilical artery toward the
bladder plate to mobilize the bladder plate (Fig.9.21c).
The peritoneum is swept off till the ureterovesical junction without disturbing
the autonomic neural plexus along the periureteric sheath. At this point, the vas
deferens can also be seen (Fig.9.21d).
While the area of the bladder dome can be mobilized in this extraperitoneal
plane, complete mobilization of the plate needs division of intersymphyseal bands,
which is to be done after exposure of the urogenital diaphragm.
Exposure ofUrogenital Diaphragm
Four pairs of stay sutures are placed on both sides of the median raphe at the penoscrotal junction, anterior surface of the scrotum, posterior surface of the scrotum,
and one in between. Exerting traction and countertraction across the stay sutures,
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9 Scrotoperineal Approach toBladder Exstrophy Repair
157
Fig. 9.20 (a, b) through the window of the umbilicoplasty ap in the subcutaneous plane; the
prefascial plane is developed down to the pubic bone on both sides of the bladder plate; (c) vesico-
cutaneous continuity is disrupted with needle tip cautery; (d) near the root of the penis, subcutaneous tissue (penile dartos) is carefully dissected and divided, sparing the underlying root of corpora
with neurovascular bundle
the scrotal septum is bisected precisely in the midline with needle tip cautery
(Fig. 9.22a). Here, an avascular plane is visible as a 0.5 mm wide white line
(Fig.9.22b). The scrotal septal vessels lateral to the midline plane are seen and
preserved to maintain clear visibility of the urogenital diaphragm.
The dissection along the white line is continued over the median raphe of penile
skin and prepuce. The penile dartos is bisected precisely in the midline over the
loose areolar tissue covering Buck’s fascia. The axial vessels of penile skin dartos
strips can be seen here on both sides of the midline (Fig.9.22c).
Near the root of the penis on both sides of the midline, an avascular subdartos
plane is created (Fig.9.22d).
The dissection along the edge of the prepuce is started, separating the inner preputial skin from the outer skin, keeping the preputial dartos toward the outer preputial and penile skin. This separation is continued to the subcoronal sulcus on the
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S. N. Kureel et al.
c d
Fig. 9.21 (a) Along the medial edge of rectus, continuity of anterior rectus sheath to linea alba is
disrupted down to the pubic tubercle; (b) below the (1) arcuate lines, the extraperitoneal plane is
created by roller gauze packing; (c) the bladder plate is mobilized in extraperitoneal plane, keeping
(2) umbilical artery toward bladder plate. (d) Complete sweeping of peritoneum up to (3) ureterovesical junction and (4) vas with spared autonomic neural plexus
ventral side and to the urethral plate margins dorsolaterally on both sides (Fig.9.23a,
b). Ventral penile skin dartos are bifurcated in the midline to create strips of penile
skin dartos complex (Fig.9.23c).
Proximally in the middle of the corpora, disruption of vascular connectivity
between the neurovascular bundle and axial vessels of the penile skin-dartos complex
is needed for complete lateral reection of the penile skin-dartos complex (Fig.9.23d).
The dissection in the avascular subdartos plane on the ventral aspect of the corpora is continued proximally, taking care to avoid invading the bulb of the urethra in
the midline and the tunica albuginea of the corpora bilaterally (Fig. 9.24a).
Dissection with ne needle tip cautery in the same avascular plane will expose the
bulbospongiosus muscle in the midline and ischiocavernosus muscle at the root of
corpora (Fig.9.24b). On the medial aspect of the ischiocavernosus muscle, the safe
innervation-preserving plane is identied as shown in Fig.9.24c, d. The posterior
scrotal vessels are identied and preserved while exiting the safe plane.
For better delineation of the anterior edge of the ischiopubic ramus, the fascia on
the muscles of the adductor compartment adjacent to the ischiopubic ramus is
reected (Fig.9.25a, b).
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9 Scrotoperineal Approach toBladder Exstrophy Repair
Fig. 9.22 (a) The scrotal septum is being bisected in midline avascular plane, (b) which is visible
as a white line in midline, (c) axial vessels of penile skin dartos are seen on both sides of the midline, and (d) near the root of the penis, an avascular subdartos plane is created on both sides of
the midline
159
The course of the neurovascular bundle can now be visualized on the dorsolateral
aspect of the corpora all the way proximally to the edge of the pubic ramus. The
intersymphyseal band is identied between the bladder plate margin and pubic bone,
above and adjacent to the corpora and neurovascular bundle. The band is lifted over
an artery forceps and released on both sides till the anterior edge of the levator ani
muscle is visible (Fig.9.26a, b). This completes the bladder mobilization.
Radical Corporal Detachment
With ne needle tip cautery, the periosteum along the anterior edge of the ischiopubic ramus is incised, taking care not to invade the adjacent corpora. On the medial
border of the pubic bone, a U-shaped incision is made over the periosteum of the
anterior and posterior aspects of the pubic bones (Fig.9.27a). A controlled, forceful
downward push with a mounted swab will separate the corporal body off the ischiopubic ramus in the subperiosteal plane without any insult to the neurovascular bundle (Fig.9.27b–d).
Complete radical detachment of corpora cavernosa will also expose the anterior
edge of the levator ani muscle, obturator surface of obturator internus muscle, and
medial aspect of ischial tuberosity, as shown in Fig.9.27d. At this stage, the osteotomy is planned.
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Fig. 9.23 (a, b) Inner preputial skin is split off outer preputial skin dartos up to subcoronal sulcus;
(c, d) ventral penile skin-dartos complex is bifurcated in the midline and reected laterally after
disconnecting tiny bridging vessels from the neurovascular bundle
S. N. Kureel et al.
Fig. 9.24 (a) Staying in the subdartos plane, continued dissection exposes the (1) bulb of the
penis and tunica albuginea of corpora; (b) Further dissection exposes (2) bulbospongiosus muscle
and (3) ischiocavernosus muscle; (c, d) close views showing the (4) safe plane
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9 Scrotoperineal Approach toBladder Exstrophy Repair
Fig. 9.25 (a, b) Fascia on the muscle of the adductor compartment adjacent to the ischiopubic
ramus is reected for precise delineation of the anterior edge of the ischiopubic ramus
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Fig. 9.26 (a, b) The
intersymphyseal band is
lifted on artery forceps and
released up to the anterior
edge of the levator ani
muscle
a
b
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Fig. 9.27 (a) Periosteum along the anterior edge of the ischiopubic ramus and medial border of
pubic bone is incised, (b) a forceful downward push with a mounted swab, (c) the subperiosteal
plane of radical corporal detachment is created, and (d) radical corporal detachment is completed,
exposing (1) levator muscle, (2) obturator internus muscle, and (3) medial aspect of ischial tuberosity
S. N. Kureel et al.
Osteotomy
At our center, osteotomy is an essential step of exstrophy repair to bring pubic
bones toward the midline and facilitate midline closure of the linea alba and rectus
muscle over the reconstructed bladder. The choice of osteotomy can be either
ischiopubic osteotomy or transverse innominate osteotomy, depending on the
extent of the gap between the pubic bones and the shape of the urogenital
diaphragm.
Ischiopubic Osteotomy
Ischiopubic osteotomy is selected in those cases where the urogenital diaphragm is
trapezoid or square and the interpubic distance is not very wide. Sites of ischiopubic
osteotomy on the superior pubic ramus and ischial tuberosity are shown in Fig.9.28a.
A notch is made on the exposed medial aspect of the ischial tuberosity using a bone
drill (Fig.9.28b). Superior and inferior aps of periosteum are reected on the pelvic surface of the superior pubic ramus, above the obturator canal. The superior
pubic ramus is cut transversely through and through with a bone drill (Fig.9.28c).
The pubic bones can now be approximated toward the midline using a bone approximator (Fig.9.28d). Partial tenotomy of adductor longus muscle attachment toward
the pubis on both sides further facilitates midline approximation of pubic bones and
helps prevent recurrent pubic bone diastasis.
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9 Scrotoperineal Approach toBladder Exstrophy Repair
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a b
Fig. 9.28 (a) Three-dimensional CT image of bony pelvis showing the site of bone cut on supe-
rior pubic ramus; a wedge of bone removed from the medial aspect of ischial tuberosity is shown.
(b) Operative picture showing creation of a notch on medial aspect of ischial tuberosity (left side)
with the help of a bone drill. (c) Operative picture showing the cutting of superior pubic ramus
(right side) with the help of a bone drill above the obturator canal. (d) Bone-holding forceps are
used to bring pubic bones toward midline. Sutures (1/0 polygalactin) are preplaced
Transverse Innominate Osteotomy
In cases with a rectangular-shaped urogenital diaphragm and a very wide gap
between pubic bones, a transverse innominate osteotomy is preferred without any
additional skin incision. The line of osteotomy extends from the greater sciatic
notch to the anterior inferior iliac spine (Fig.9.29a, b). A roller gauze packing
medial to the greater sciatic notch before cutting the bone displaces the sciatic
nerve medially and provides a cushion between the greater sciatic notch and the
sciatic nerve. This maneuver prevents the possibility of osteotome-induced injury
to the sciatic nerve. Pubic bone approximation is done with two or three sutures
of 1-0 or number 1 polygalactin. The radical corporal detachment done earlier
prevents the inevitable retraction of the penis when the pubic bones are
approximated.
With either osteotomy, there is no need for external xators, limb immobilization, or plaster casts.
Corporal-Urethral Separation
Safe corpora-urethral separation with preservation of the neurovascular bundle and
sphincteric branch of the perineal nerve, bulb of the urethra, periprostatic plexus,
cavernous nerve, vascularity of corpus spongiosum and urethral plate, and
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S. N. Kureel et al.
Fig. 9.29 (a, b) Three-
dimensional CT image of
bony pelvis showing the
line of osteotomy from
greater sciatic notch to
anterior inferior iliac spine
a
b
vascularity of the corpus cavernosa and glans is the key to further reconstruction for
continence.
Staying in the subfascial plane of Buck’s fascia medial to the neurovascular bundle and lateral to the margin of the urethral plate, corpora are separated off the
central wedge of corpus spongiosum and urethral plate (Fig.9.30a, b).
Proximally, the dissection continues in the safe plane, preserving the innervation
of the rhabdosphincter, and the corpora are separated off the external urethral
sphincter, bulb, posterior urethra, bladder neck, and periprostatic plexus
(Fig.9.30c, d).
Reconstruction
An area vertically between the ureteric orice and verumontanum with width equal
to the width of the proximal urethral plate at verumontanum is marked for the bladder neck. Lateral triangular mucosal patches from the margin of the bladder neck
are excised on both sides as shown in Fig.9.31a.
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9 Scrotoperineal Approach toBladder Exstrophy Repair
Fig. 9.30 (a) The subfascial plane entered medial to neurovascular bundle and lateral to urethral plate
margin; a wedge of corpus spongiosum is separated off the medial aspect of corpora cavernosa. (b)
Working in the subfascial plane from the ventral side, dissection continues to enter the plane created
from the dorsal side. (c) Working in the subfascial plane on corpora toward bladder neck; posterior
urethra, bulb, and bladder neck are separated off the corpora, preserving the vessels and periprostatic
plexus. (d) On the ventral side, working in the safe plane, both limbs of the bulbospongiosus and
adjacent external urethral sphincter are separated off the corpora with preserved innervation
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Fig. 9.31 (a) A triangular mucosal patch from the bladder plate margin is excised, keeping area
of width equal to posterior urethra length between ureteric orices and verumontanum, (b, c) 4/0
polygalactin sutures are placed across the bladder over the feeding tube and tied off for anatomical
bladder neck reconstruction, and (d) the bladder is closed with ureteric stent, vesical stent, and
urethral stent in place