Cobertura ventral de Neouretroplastias e Ortofaloplastias, utilizando retalho transverso em ilha do prepúcio, nas correções de hipospádias proximais do sexo masculino
Arquivos
Data
2022-10-14
Tipo
Tese de doutorado
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Título de Volume
Resumo
Esta tese tem como objetivo, apresentar uma técnica desenvolvida em 2001, utilizando o retalho transverso em ilha do prepúcio, como forma de cobertura da falha ventral no tratamento de hipospádias proximais após a neouretroplastia, e nas ortofaloplastias como primeiro tempo nas cirurgias em estágios.
Enquanto o tratamento de hipospádias na forma distal é bem definido na literatura, há discussão acerca de qual o melhor procedimento para a forma proximal, em tempo único ou em estágios, com utilização de retalhos prepuciais tubulizados ou não, enxertos de pele ou de mucosas, necessidade e tipos de corporoplastias, aproveitamento ou não da placa uretral, tipos de cobertura da neouretra e da falha ventral, entre outros.
Desde 1982, adquirimos experiência com o uso de retalhos tubulizados e duplos retalhos transversos do prepúcio, e introduzimos modificações técnicas para reduzir complicações na correção de hipospadias proximais em tempo único. Entretanto, ao constatarmos que a maioria das complicações estavam relacionadas à porção tubulizada, não ao retalho utilizado para cobertura da falha ventral, decidimos modificar nossos procedimentos e preservar a placa uretral para a formação da neouretra quando possível. Assim, a partir de 2001, passamos a utilizar o retalho em ilha transverso do prepúcio, como forma de cobertura da falha ventral tanto no tratamento de hipospádias proximais, após a neouretroplastia, quanto nas ortofaloplastias, como primeiro tempo nas cirurgias em estágios.
Apresentaremos os resultados de 38 meninos portadores de hipospádia proximal, sendo que 26 foram submetidos à neouretroplastia primária pela técnica de TIP (“Tubulized Incised Plate” longo), e 12 realizaram ortofaloplastias como primeiro tempo de cirurgia estagiada. Em ambas as técnicas a cobertura da falha ventral foi realizada com retalho transverso do prepúcio, sendo utilizado desepitelização das bordas laterais e inferiores, nos casos de cirurgia em tempo único (TIPM). Nosso interesse primário foi o de avaliar tecnicamente a utilização do retalho do modo preconizado, bem como a incidência de complicações, e verificar se este tipo de
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cobertura da neouretra alteraria os índices das principais complicações de neouretroplastias longas.
A média da idade por ocasião do tratamento cirúrgico para ambos os grupos (TIPM e Ortofaloplastia para a cirurgia em estágios) foi de 38,6 meses, com um período de seguimento médio de 37,1 meses. Houve necessidade de corporoplastias em 50% das cirurgias em tempo único e em 25% nos casos de cirurgia estagiada. Não ocorreu nenhuma complicação vascular no retalho ventral, verificando-se epidermólise superficial no prepúcio dorsal remanescente em 2 dos 26 casos de tempo único. Ocorreu deiscência parcial do retalho em 3 casos de TIPM e em um de Ortofaloplastia.
As complicações tardias foram de curvatura residual em apenas um caso de ortofaloplastia, sem corporoplastia, realizada na primeira cirurgia, fístula da neouretra em 3 dos 26 casos (11,5%) de TIPM, e cistos de inclusão dérmica decorrentes da desepitelização das bordas do retalho em 7 dos 26 casos (27%) de correção em tempo único.
Utilizando critérios preestabelecidos para classificação de resultados, obteve-se 77% de bons e 23% de regulares no aspecto plástico, e 88,5% de bons e 11,5% regulares, como resultados funcionais para as cirurgias em tempo único. Para a cirurgia estagiada, apenas o aspecto plástico-estético foi avaliado com resultado de 92% bom e 8% regular.
Após as reoperações no grupo TIPM, de 9 cirurgias em 7 pacientes, com média de 1,34 cirurgias por paciente neste grupo, obteve-se 96% de bons resultados plásticos e 100% funcionais.
Conclui-se que a nas correções de hipospadias proximais, a utilização do retalho transverso em ilha do prepúcio, na cobertura ventral de ortofaloplastias e neouretroplastias, com preservação da placa uretral tubulizada, é seguro e sem complicações vasculares no retalho. Contribui também, para uma diminuição na incidência de complicações, reoperações e, ainda, apresenta uma ótima camada de pele para futura tubulização nos casos de cirurgia em estágios.
This thesis objective is to present a technique developed in 2001 that uses the transverse island flap of the foreskin as a form of coverage of the ventral failure in the treatment of proximal hypospadias after neourethroplasties, and orthophaloplasties as the first stage procedure. While the treatment of distal hypospadias is well-documented in the literature, there is debate on which would be the best procedure in proximal hypospadias, if single or multiple stages procedures, the use of tubulized or not preputial flaps, use of skin or mucosal grafts, need and types of corporoplasties, preservation or not of the urethral plate, types of coverage of the neourethra and ventral failure, among others. From 1982, we have acquired experience in the use of tubulized flaps and double transverse flaps of the foreskin for proximal hypospadias forms, including our own technical modifications to decrease the complications rate in a one-stage hypospadias corrections. However, realizing that most complications were related to the tubulized portion, and not in the flap used as a cover of ventral failure, and keeping in mind the interest in preservation, we have decided to modify our procedures and preserve the urethral plate, with primary tubulization for the formation of neourethra. Therefore, since 2001, we decided to use a transverse island flap of the foreskin as a form of coverage of the ventral failure in the treatment of proximal hypospadias after neourethroplasties; similarly, this has been used in orthophaloplasties as the first-stage procedure. We present the results of 38 boys with proximal hypospadias, 26 of which were submitted to primary neourethroplasty by the Tubulized Incised Plate technique and 12 which underwent orthophaplasties as the first-stage surgery. In both techniques, the coverage of ventral failure was performed with a transverse flap of the foreskin, with deepithelialization of the lateral and inferior edges used in cases of single-stage surgery (TIPM). Our primary interest was to technically evaluate the use of the flap in the recommended way, as well as the incidence of complications, and to verify whether this type of neourethra coverage would change the rates of the main complications of long neourethroplasties. The mean age at the time of surgical treatment for both groups (TIPM and Orthophaloplasty) was 38.6 months, with a mean follow-up period of 37.1 months. There was need for corporoplasties in 50% of single and in 25% of the cases of the staged surgeries. There was no vascular complication in the ventral flap, and superficial epidermolysis occurred in the remaining dorsal foreskin in 2 of the 26 of the one-stage procedures. Partial flap dehiscence occurred in 3 cases of TIPM and in one of Orthophofaloplasty. Late complications were: residual curvature in only one case of Orthophoplasty without previous corporoplasty in the first surgery; neourethra fístula in 3 of the 26 cases (11.5%) of TIPM; and dermal inclusion cysts resulting from the of deepithelialization of the flap edges in 7 of the 26 cases (27%) of single-stage corrections. Using pre-established criteria for classification of results, 77% were classified as good and 23% as regular in the plastic aspect, and 88.5% as good and 11.5% as regular (correction of fístulas) as functional results for surgeries in the single-stage group. For the staged surgery only the plastic aesthetic aspect was evaluated with a result of 92% good and 8% regular (1 case with residual curvature). After reoperations in the TIPM group, 9 surgeries were conducted in 7 patients, with an average of 1.34 surgeries per patient in this group: 96% of good plastic and 100% functional results were obtained. We conclude that in the corrections of proximal hypospadias the use of the transverse island flap of the foreskin in the ventral coverage of orthophaplasties and neourethroplasties with preservation of the tubulized urethral plate is safe, with no vascular complications in the flap resulting from the technique. The technique contributes to a decrease in the incidence of complications and reoperations, and still represents an excellent layer of skin for future tubulization in cases of staged surgeries.
This thesis objective is to present a technique developed in 2001 that uses the transverse island flap of the foreskin as a form of coverage of the ventral failure in the treatment of proximal hypospadias after neourethroplasties, and orthophaloplasties as the first stage procedure. While the treatment of distal hypospadias is well-documented in the literature, there is debate on which would be the best procedure in proximal hypospadias, if single or multiple stages procedures, the use of tubulized or not preputial flaps, use of skin or mucosal grafts, need and types of corporoplasties, preservation or not of the urethral plate, types of coverage of the neourethra and ventral failure, among others. From 1982, we have acquired experience in the use of tubulized flaps and double transverse flaps of the foreskin for proximal hypospadias forms, including our own technical modifications to decrease the complications rate in a one-stage hypospadias corrections. However, realizing that most complications were related to the tubulized portion, and not in the flap used as a cover of ventral failure, and keeping in mind the interest in preservation, we have decided to modify our procedures and preserve the urethral plate, with primary tubulization for the formation of neourethra. Therefore, since 2001, we decided to use a transverse island flap of the foreskin as a form of coverage of the ventral failure in the treatment of proximal hypospadias after neourethroplasties; similarly, this has been used in orthophaloplasties as the first-stage procedure. We present the results of 38 boys with proximal hypospadias, 26 of which were submitted to primary neourethroplasty by the Tubulized Incised Plate technique and 12 which underwent orthophaplasties as the first-stage surgery. In both techniques, the coverage of ventral failure was performed with a transverse flap of the foreskin, with deepithelialization of the lateral and inferior edges used in cases of single-stage surgery (TIPM). Our primary interest was to technically evaluate the use of the flap in the recommended way, as well as the incidence of complications, and to verify whether this type of neourethra coverage would change the rates of the main complications of long neourethroplasties. The mean age at the time of surgical treatment for both groups (TIPM and Orthophaloplasty) was 38.6 months, with a mean follow-up period of 37.1 months. There was need for corporoplasties in 50% of single and in 25% of the cases of the staged surgeries. There was no vascular complication in the ventral flap, and superficial epidermolysis occurred in the remaining dorsal foreskin in 2 of the 26 of the one-stage procedures. Partial flap dehiscence occurred in 3 cases of TIPM and in one of Orthophofaloplasty. Late complications were: residual curvature in only one case of Orthophoplasty without previous corporoplasty in the first surgery; neourethra fístula in 3 of the 26 cases (11.5%) of TIPM; and dermal inclusion cysts resulting from the of deepithelialization of the flap edges in 7 of the 26 cases (27%) of single-stage corrections. Using pre-established criteria for classification of results, 77% were classified as good and 23% as regular in the plastic aspect, and 88.5% as good and 11.5% as regular (correction of fístulas) as functional results for surgeries in the single-stage group. For the staged surgery only the plastic aesthetic aspect was evaluated with a result of 92% good and 8% regular (1 case with residual curvature). After reoperations in the TIPM group, 9 surgeries were conducted in 7 patients, with an average of 1.34 surgeries per patient in this group: 96% of good plastic and 100% functional results were obtained. We conclude that in the corrections of proximal hypospadias the use of the transverse island flap of the foreskin in the ventral coverage of orthophaplasties and neourethroplasties with preservation of the tubulized urethral plate is safe, with no vascular complications in the flap resulting from the technique. The technique contributes to a decrease in the incidence of complications and reoperations, and still represents an excellent layer of skin for future tubulization in cases of staged surgeries.