Tubularized Flap Research Articles

Jejunum free flap for head and neck reconstruction, a step-by-step surgical technique videos.

Circular pharyngolaryngectomy for oncologic resection requires a tubular reconstruction. Different options can be proposed to the patient: digestive free flap, fasciocutaneous flap, or musculocutaneous flap. The jejunum free flap is a tubular flap commonly used in esophageal and pharyngeal reconstruction with good functional outcomes and an acceptable rate of complications. Reconstruction with a jejunum free flap is an ideal choice. Patients at Gustave Roussy Institute (Villejuif, France) were offered a jejunum flap free flap for all circular pharyngolaryngectomies. The surgical technique is explained with a step-by-step video. The jejunum flap free flap has many advantages in circular pharyngolaryngectomy. This video article explains surgical steps for other teams.

Long-Term Bowel Vaginoplasty With a Single Yang-Monti Tube.

The bowel remains the favored tissue for neo-vaginoplasty (NeoVP) in pediatric patients with vaginal agenesis. In 2001, the first description of NeoVP using the Yang-Monti technique with a sigmoid double tubular flap was published. We present our experience of NeoVP with a single Yang-Monti tube (SYMT) flap and report on the use of different segments of colon. We conducted a retrospective review of patients who underwent NeoVP using a bowel SYMT between 2009 and 2021. The procedure was performed under open abdominal surgery by isolating 8 to 12 cm from the rectosigmoid, cecum, or ascending colon. Subsequently, this segment was detubularized near the mesenteric border, folded, and retubularized transversally, leaving the mesentery in a cephalic position. A channel was dissected in the pelvis to accommodate the NeoVP. Seventeen patients were identified. The median age was 16 years old. The principal diagnosis was Mayer-Rokitansky's syndrome (47.1%). The median follow-up was 50 months. The mean harvested bowel length was 9 cm, and the sigmoid was the preferred site (65%). The cecum-ascending colon was used in 3 (17.6%) patients. Complications were recorded in 6 patients (35%). Of these 6 patients, 4 had introital stenosis. There was 1 case of urethrovaginal fistula and another of left hematometrocolpos. Satisfactory sexual function has been reported in sexually active individuals. We described our experience in NeoVP using a large bowel SYMT as a safe and effective technique. It allows decreased tension on the vascular pedicle and the use of shorter colon segments.

V09-06 SINGLE-PORT ROBOT-ASSISTED TUBULARIZED URACHUS-PERITONEAL HINGE-FLAP SALVAGE GENDER-AFFIRMING VAGINOPLASTY

You have accessJournal of UrologyCME1 Apr 2023V09-06 SINGLE-PORT ROBOT-ASSISTED TUBULARIZED URACHUS-PERITONEAL HINGE-FLAP SALVAGE GENDER-AFFIRMING VAGINOPLASTY Maurice Garcia, Shannon Smith, Jenna Stelmar, Nance Yuan, Amit Gupta, Samhita Mallavarapu, and Hyung Kim Maurice GarciaMaurice Garcia More articles by this author , Shannon SmithShannon Smith More articles by this author , Jenna StelmarJenna Stelmar More articles by this author , Nance YuanNance Yuan More articles by this author , Amit GuptaAmit Gupta More articles by this author , Samhita MallavarapuSamhita Mallavarapu More articles by this author , and Hyung KimHyung Kim More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003317.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: A morbid complication of gender affirming vaginoplasty surgery is loss neovaginal canal depth. Options to restore depth are limited. Some surgeons describe increasing depth by opening the fore-shortened vaginal canal into the pelvis and then gathering peritoneum adherent to the bladder and rectum together to enclose the vaginal canal opening into pelvis. Two principal disadvantages of this technique are that: 1. The rectum is, by necessity, incorporated as a wall of the vaginal canal; and 2. The gathering sutures remain to tension, especially during rectal filling. We describe a novel alternative technique that utilizes peritoneum from the urachus and anterior bladder dome to restore vaginal length, and show that it can be easily performed via a dual approach using a single-port robot-assisted and trans-vaginal technique. We also highlight technical innovations we developed. METHODS: From a view optimized by the Lap SP camera, we identify the location of the remnant vaginal canal vault, and incise the peritoneum horizontally over a dilator in the canal space. Anterior vaginal canal is anastomosed to peritoneum anterior to the incision, and the peri-umbilical end of our flap (Figure 1a) is anastomosed to the posterior edge. Our flap completely anteriorly based (uses a 3-layer flap of peritoneum, urachus and Transversalis fascia, from the umbilicus to the anterior bladder dome), and completely excludes the rectum. Our tubularized flap suture-lines are subject to tension only during filling of the vaginal canal, and has no sutures at the vault-end. RESULTS: (See video) Our novel technical innovations not described in the literature for peritoneal vaginoplasty include: 1. Design of a novel hollow vaginal dilator for intra-op (lighted transillumination) and post-op use (dilation/douching) (b-d); 2. Vaginal insertion of our lighted dilator to confirm location of the remnant vaginal-vault (e); 3. Excision of the Seminal vesicles to un-obstruct the canal space (f); and 4. A spatulated/offset anterior/posterior vaginal-peritoneal anastomosis (g). CONCLUSIONS: Our flap is based on anatomy quite familiar to the urologic surgeon: the urachus. It is technically simple to perform, and our innovations render it safer with better outcomes. Clinical outcomes presented in: Smith, Garcia, et al, Sex. Med., 2022. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e838 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Maurice Garcia More articles by this author Shannon Smith More articles by this author Jenna Stelmar More articles by this author Nance Yuan More articles by this author Amit Gupta More articles by this author Samhita Mallavarapu More articles by this author Hyung Kim More articles by this author Expand All Advertisement PDF downloadLoading ...

Reconstruction of Pharyngolaryngeal Defects with the Ileocolon Free Flap: A Comprehensive Review and How to Optimize Outcomes.

Several reconstructive methods have been reported to restore the continuity of the aerodigestive tract following resection of pharyngeal and hypopharyngeal cancers. However, high complication rates have been reported after voice prosthesis insertion. In this setting, the ileocolon free flap (ICFF) offers a tubularized flap for reconstruction of the hypopharynx while providing a natural phonation tube. Herein, we systematically reviewed the current evidence on the use of the ICFF for reconstruction of the aerodigestive tract. A systematic literature search was conducted across PubMed MEDLINE, Web of Science, ScienceDirect, Scopus, and Ovid MEDLINE(R). Data on the technical considerations and surgical and functional outcomes were extracted. Twenty-one studies were included. The mean age and follow-up were 54.65 years and 24.72 months, respectively. An isoperistaltic or antiperistaltic standard ICFF, patch flap, or chimeric seromuscular-ICFF can be used depending on the patients' needs. The seromuscular chimeric flap is useful to augment the closure of the distal anastomotic site. The maximum phonation time, frequency, and sound pressure level (dB) were higher with ileal segments of 7 to 15 cm. The incidence of postoperative leakage ranged from 0 to 13.3%, and the majority was occurring at the coloesophageal junction. The revision rate of the microanastomosis ranged from 0 to 16.6%. The ICFF provides a reliable and versatile alternative for reconstruction of middle-size defects of the aerodigestive tract. Its three-dimensional configuration and functional anatomy encourage early speech and deglutition without a prosthetic valve and minimal donor-site morbidity.

Comprehensive Evaluation of Vocal Outcomes and Quality of Life after Total Laryngectomy and Voice Restoration with J-Flap and Tracheoesophageal Puncture.

Simple SummaryLaryngopharyngectomy is still the treatment of choice in locally advanced pharyngolaryngeal tumors not eligible for organ preservation protocols. Loss of speech capacity has been reported as one of the factors that most affect the patient-reported quality of life. Thus, the reconstructive goals are restoring the pharynx and possibly the voice in such a scenario. For decades, tracheoesophageal puncture (TEP) has allowed proper voice rehabilitation; however, TEP has a non-neglectable financial expenditure and complication rate. Therefore, we recently reported a novel flap design and surgical technique that shares the same principles of TEP, without the need to change any device over time, named J-flap. This study aimed to analyze both techniques’ subjective and objective vocal outcomes and their impact on overall and voice-related quality of life.Background: Tracheoesophageal puncture with a voice prosthesis is the gold standard for speech rehabilitation in patients that receive a laryngopharyngectomy. However, a novel surgical technique, using a tubularized anterolateral tight flap, named “J-flap,” has been demonstrated to produce adequate voice restoration. We aimed to compare the outcomes and the quality of life of patients who underwent voice rehabilitation with both techniques. Methods: We enrolled patients that underwent laryngopharyngectomy and voice restoration surgery. The control group received a tracheoesophageal puncture with a voice prosthesis, while the study group received J-flap reconstruction. A total of 20 patients received voice prosthesis rehabilitation, while 18 received J-flap reconstruction. Speech and vocal outcomes and quality of life metrics were collected. Results: The objective phonatory performances and the acoustic voice analysis did not outline a significant difference. Speech pathologists judged the consonant pronunciation in the J-flap group as less accurate (p < 0.001). The voice handicap index revealed a moderate impairment for the J-flap group (p < 0.001). Quality of life scores were higher for the voice prosthesis group. Conclusion: Voice prostheses and J-flaps share similar objective phonatory outcomes. Quality of life was more impaired in the J-flap group. In our view, these two techniques possess complementary characteristics in clinical practice, taking into account health care system regulations and patients’ social background.

Fatal complications in reconstructive plastic surgery and ways of their prevention

The world experience and experience of the Institute of Microsurgery (Tomsk, Russia) in rescuing dying free flaps are summarized in the paper. The issues related to the prevention of vascular disorders, which in 85–95% of cases lead to fatal complications in the form of total necrosis of the reperfused flap, are discussed. We are talking about the immediate, early and late complications due to the compromise of blood flow along the vascular pedicle (arterial, venous, arterial-venous). Unlike irreversible disorders, temporary disturbances in blood supply in free flaps are caused by the consequences of primary ischemia and reperfusion. Their duration and reversibility depend on the tissue composition, i.e. from the anoxic resistance of the tissues constituting the flap and, of course, the structures that form the wall of the flap vessels themselves. With a short duration of primary ischemia (up to 1 hour) and compensated reperfusion syndrome, temporary vascular disorders are manifested by flap skin flushing and metabolic edema of its tissues, which disappear 10-40 minutes after reperfusion. The indications for revision of the vascular pedicle are doubts about the adequacy of blood flow in the flap due to the appearance of the first signs of anastomotic thrombosis. The highest rates of flap rescue are achieved after revision of the vascular pedicle no later than 90 minutes after the first signs of thrombosis appear. It is important that the surgeon performing these microvascular anastomoses does the revision. The development of technologies for rescuing a perishing flap has become especially relevant in the last decade. This is due to the rapid development of reconstructive microsurgery of head and neck tumors. In such patients, there is practically no alternative to free transplantation of tissue complexes for the reconstruction of the lower jaw, tongue, soft tissue defect of the lower face and neck. The main technical problem leading to fatal complications after transplantation of a radial, peroneal, anterolateral femur flap is the difficulty of finding recipient vessels suitable for revascularization in soft tissues previously exposed to radiation. The search for alternative recipient vessels during the primary reconstruction of defects, for example, in the oral cavity, is accompanied by a significant increase in the duration of primary ischemia (up to 3–4 hours) and the death of flaps. The preservation of the viability of such free flaps is possible only by their temporary extracorporeal perfusion with extracorporeal membrane oxygenation. It is possible to preserve the viability of free flaps for 2 weeks (without microvascular anastomoses) during tertiary reconstruction of head and neck defects by continuous extracorporeal perfusion of the flap until it is completely engrafted in the recipient area. There is experience of using a tubular non-free radial flap on the long vascular pedicle of the radial vascular bundle (from the wrist to the ulnar fossa) in tertiary tissue reconstruction after removal of head and neck tumors.

Reconstruction of the large columella defect with Сchmid-Мeyer flap

Introduction. The reconstruction of columella defects is still regarded as a challenging procedure due to the very specific anatomy of the columella and limited local and regional flap options. Furthermore, the texture and color of columella tissue pose difficulties in choosing the right method of reconstruction. Case report. The report presents a patient who underwent reconstruction of a complex columella defect using a Schmid-Meyer flap. Schmid-Meyer flap represents a tubular flap with an internal supraciliary pedicle which allows the transposition of the temporal skin with the addition of ear cartilage on the tip of the nose or the ala nasi. The integration of the flap was complete. During the five-year follow-up period, the cosmetic and functional results were satisfying. Conclusion. Schmid-Meyer flap may be one of the best options for the reconstruction of complex defects of the columella.

Use of retroauricular tubular flap for ear helix and ear lobe reconstruction

A Revista Brasileira de Cirurgia Plástica é o órgão oficial de divulgação da Sociedade Brasileira de Cirurgia Plástica (SBCP), tem como objetivo registrar a produção científica em Cirurgia Plástica, fomentar o estudo, aperfeiçoamento e atualização dos profissionais da especialidade.

Retalho tubular subdérmico para reconstrução dorsal nasal em cão dolicocefálico: relato de caso

This case report described the use of tubular subdermal flap to dorsal nasal reconstruction of an old dolichocephalic dog. A nine-year-old Dachshund female dog-weighing 10 kg presented with deep and extensive wound in the dorsal nasal region was attended at veterinary clinic, Sorocaba city, São Paulo, Brazil. The reconstructive surgical procedure was performed in three stages with an interval time of 25 days, which included the preparation of the tubular subdermal flap; the advance of the flap to the region of the tissue defect, and the removal of excess flap. The region healed 14 days after the last stage. The tubular subdermal flap was effective for treating ulcerative epithelial wounds associated with interstitial lymphoplasmocyte dermatitis and vasculitis of the dorsal nasal region of an old Dachshund dog.

Evaluation of the effectiveness of the tuba uterina tubular flap in the peripheral nervous system regeneration in rats

Nerve conduits could be used to provide a bridge between both nerve endings. In this study, the tuba uterina of female rats were prepared in a vascularized pedicled flap model and it used as a nerve conduit. The aim was to investigate the effectiveness of a vascularized pedicle nerve conduit and its ciliated epithelium in a sciatic nerve defect. The study was conducted between May and August 2018, and used a total of 60, 14–16-week-old female Wistar albino rats. Six groups were created; Cut and Unrepaired Group, Nerve Graft Group, Flap-Forward Group (Tuba uterina tubular flap, forward direction), Flap-Reversed Group (Tuba uterina tubular flap, reverse direction), Graft-Forward Group (Tuba uterina tubular graft, forward direction) and Graft-Reverse Group (Tuba uterina tubuler graft, reverse direction). Nerve regeneration was evaluated 3 months (90 days) after the surgery by the following methods: (1) Sciatic Functional Index (SFI) measurement, (2) Electromyographic (EMG) assessment, (3) Microscopic assessment with the light microscope and (4) Microscopic assessment with the electron microscope. According to the SFI, EMG and microscopic assessments with the light and electron microscope, it was observed that the transfer of tuba uterina tubular conduit as a graft was statistically better in its effect on nerve regeneration than flap transfer, but also indicated that the direction of the ciliated structures had no significant effect. We believe that as this model is improved with future studies, it will shed light on new models, ideas and innovations about nerve conduits.

Yeni Pyeloplasti Tekniği; Tekrarlayan Üretero-pelvik Bileşke Obstrüksiyonunun Onarımında Renal Pelvis Tübülerize Flep Kullanılması

Yeni Pyeloplasti Tekniği; Tekrarlayan Üretero-pelvik Bileşke Obstrüksiyonunun Onarımında Renal Pelvis Tübülerize Flep Kullanılması

Five years' experience of double faced tubularized preputial flap for penoscrotal hypospadias repair in pediatrics

The success of techniques for proximal hypospadias repair using vascularized preputial flaps has led to their wide application for the last decade. From these techniques, transverse tubularized preputial flaps are particularly attractive. However, high reported rate of complications, including recurrence and urethro-cutaneous fistulae are still challenging the success of these techniques, probably related to vascular insufficiency for the lengthy neourethra. Therefore, many surgeons trying to improve the outcome by utilizing the unique vascular benefits of double faced preputial flap. the present study tries" to evaluate double faced tubularized preputial flap technique for incidence of complications, in comparison with the standard ventral tubularized preputial flap, and to evaluate also surgical outcomes regarding the clinical urinary function and cosmetic results. This was a prospective controlled randomized study, included 160 patients with peno-scrotal hypospadias, conducted at Al-Azhar University hospitals, from January 2014 to January 2019. All patients submitted to one-stage repair. Eighty patients underwent double faced tubularized preputial flap technique (group A) and 80 patients underwent standard ventral preputial tubularized flap technique (group B). Different complications were reported in 12 patients (15%) in group A, compared to 20 patients (25%) in group B. The difference between the complication rates in both groups was statistically significant. 152 of 160 children (95%) had good clinical urinary functional outcomes (short micturition time, good urinary stream without straining or post voiding dribbling) and satisfactory cosmetic results obtained by parents' questioner at follow up visits. This article presents an evaluation of double faced tubularized preputial flap technique in comparison to standard ventral preputial tubularized flap technique (Duckett) in one-stage peno-scrotal hypospadias repair, regarding surgical outcomes, rate of complications, clinical urinary function and satisfactory cosmetic results. Double faced tubularized flap repair is a good option to reconstruct penoscrotal hypospadias after correction of chordee which have fewer complications and also shows that transferring the tube with its skin appears to achieve better ventral skin covering. Double faced tubularized preputial flap technique seems to be a superior option, that provide better vascular supply with better results when compared to standard ventral preputial tubularized flap in one-stage peno-scrotal hypospadias repair, with reported fewer complications, better urinary function and good cosmetic results.

Assessment of prognostic factors for reconstruction of the upper third of the ureter with a tubularized pelvis flap

Ureteral plastic with a tubularized pelvic flap is a rare option of ureteral reconstruction. We present the assessment of the factors that are important for predicting the success of this operation.The aim. The purpose of the study was to assess the factors that are important in predicting the success of reconstruction of the upper third of the ureter with a tubularized pelvis flap.Material and methods. The study included 73 patients who were divided into 2 groups. The first group had extended strictures of the upper third of the ureter (n=14 / 19.2 %), and the second group had pathology of the ureteropelvic junction associated with ureterovascular conflict (n=59 / 80.8 %).Results. The length of the pelvic flap varied from 2.5 to 10.0 cm and reached an average of 3.9 cm. Early postoperative complications (Clavien-Dindo gradation <3) were observed in 14 (9.2 %) patients out of 73, and dominated in the first group. The total number of positive long-term results (good + satisfactory) was 97.3 %. Two poor results were reported only in patients of the first group with prolonged recurrent strictures. A significant factor in the prognosis of complications was the secondary nature of the operation (p <0.004). The factors of the long-term results prognosis were the performance of dismembered tubularized flap pyeloplasty due to the extended strictures of the upper third of the ureter, and the duration of the operation more than 120 minutes (p <0.009 and p <0.026).Conclusion. Surgical correction of the upper third of the ureter by a tubularized pelvis flap is a highly effective and safe method of reconstruction of the upper urinary tract. The main negative factors in the prognosis of this operation results are the secondary nature of the operation, the performance of the dismembered tubularized flap pyeloplasty because of the extended strictures of the upper third of the ureter, and the duration of the operation more than 120 minutes

Redo Hypospadias Repair: Comparison of Three Different Methods

Purpose: To evaluate the clinical data and treatment outcomes of 3 different methods for redo hypospadias surgery. Patients and Methods: We retrospectively reviewed the data of 39 patients with redo hypospadias surgery between January 2010 and April 2019 at our clinic. A ventral preputial onlay flap, a preputial tubular flap, and a full thickness skin tubular graft were used in redo hypospadias surgery. We evaluated these methods regarding age, number, and type of previous repairs, catheter time, chordee, length of the urethral defect, operation time, complications, and follow-up results. T tests and Fisher’s exact tests were used to compare differences between groups. Results: The mean operation age of the patients was 5.23 years. Sixteen patients had a single, 21 had 2, and 2 patients had 3 previous repairs. The position of the urethral meatus was perineal in 2, penoscrotal in 6, mid penile in 21, and distal penile in 10 patients. The initial repairs comprised 19 tubularized incised plates (TIP), 12 Mathieu procedures, 5 tubularized preputial flaps, 2 full thickness skin tubular grafts, and 1 onlay island flap repair. Eight full thickness skin tubular grafts, 18 onlay preputial island flaps, and 13 preputial tubular flaps were used for redo surgery. The success rate was 79.1%. Eight wound infections, 6 glans dehiscences, 13 fistulas, 12 meatal stenoses, and 5 urethral diverticulas were seen in the patients. The rates of these complications, Cystofix requirement, and reoperation were higher in the skin tubular graft group but this was not statistically significant (p > 0.05). One patient with graft contracture required a redo skin graft urethroplasty. The mean follow-up duration was18 months. Conclusion: Preputial tissue should be preferred in the presence of redo hypospadias surgery. In the absence of preputial tissue other tissues such as oral or buccal mucosa should be preferred instead of skin grafts.

Application of a Meshed Skin Graft in the Surgical Bed Immediately after Resection of Neurofibrosarcoma in the Distal Limb Region of a Dog

Background: Malignant peripheral nerve sheath tumors are neurogenic neoplasms that originate from cells that surround the axons of peripheral nerves. Surgery is the treatment of choice for peripheral nerve sheath tumors. They have a better prognosis when the lesion is in the extremity of a limb and the surgeon leaves wide peripheral margins after resection. However, this procedure makes local treatment a challenge due to difficult wound healing in this region. This report describes a successful case involving the use of a meshed skin graft immediately after resection of a neurofibrosarcoma in the distal region of the radius bone of a dog.Case: A 6-year-old Boxer bitch weighing 40 kg was admitted with a history of a round, firm, non-ulcerated skin nodule attached to the lateral side of the distal region of the right radius bone, which had been present for about 40 days. Fine needle aspiration cytology of the lesion showed the presence of mesenchymal cells, suggesting a sarcoma. Thus, the decision was made for an incisional biopsy to confirm the diagnosis and for the preparation of a subdermal pattern tubular flap for subsequent rotation and transposition to close the wound that would be formed after the complete removal of the lesion. After the 7th postoperative day, the diagnosis of low-grade neurofibrosarcoma was confirmed and due to the presence of necrotic onset in the middle portion of the tubular flap, further surgical intervention was scheduled for the resection of the tube flap, en bloc removal of the neoplastic lesion with peripheral margins of 2 cm, and wound closure with a free skin graft. A mesh skin graft was made with a portion of the right flank skin. The mesh graft was carefully implanted on the recipient bed using simple interrupted sutures with a 3-0 non-absorbable monofilament suture material. A dressing made with water-based sterile lubricating solution and gauze and a modified Robert Jones bandage were applied. The patient was treated with analgesic medication, antimicrobial therapy, and gastric protectors. The first bandage and dressing were changed after 48 h, and only warm physiological solution was used. Histopathological analysis confirmed the diagnosis of low-grade neurofibrosarcoma with free surgical margins. The dressing was changed every 72 h for up to 12 postoperative days, when the immobilization was removed, and wound cleaning could be completed at home using physiological solution and a dressing with nitrofurazone ointment. Granulation tissue was first seen at day 12, and at day 30 the wound was completely closed.Discussion: The primary closure of skin defects after the resection of tumors located in the distal portion of limbs is often not possible due to a lack of adjacent skin. Thus, grafts are commonly used to repair the skin in these areas using the technique presented in this report. In order to survive, skin grafts need a vascular bed capable of allowing new blood vessel connections with the implanted skin portion. There is no consensus in the literature on the best bed for graft implantations. In the case described in this study, a free mesh graft was implanted on a fresh wound without granulation tissue, which resulted in excellent clinical evolution and total survival of the graft. Excellent clinical results were achieved with the graft, since its survival and adherence to the recipient bed occurred without complications. The clinical result of this case suggests that the application of full-thickness mesh grafts to fresh wounds in distal limbs immediately after tumor resection is a good alternative when the surgical wound is too large (which prevents primary closure). Good preoperative planning associated with good surgical techniques and adequate postoperative management are essential for the success of the technique under these conditions.

V89 - One-stage preputial island tubularized flap repair for cripple hypospadias in adults. A step-by-step technique

V89 - One-stage preputial island tubularized flap repair for cripple hypospadias in adults. A step-by-step technique

Features of surgical tactics in traumatic amputations of limbs

The frequency of traumatic amputations is constantly growing, which is associated with the development of transport and modern technology, military conflicts. Aim: To improve the results of treatment of patients with wound and functional defects after injury by developing a comprehensive program of surgical treatment to restore the shape and function of the trunk and limbs. Materials and methods. From 2010 to 2016 52 patients were observed in the clinic. Traumatic amputations at the hip level were observed in 14 patients, at the level of the upper third of the tibia – in 7 patients, at the level of the lower third of the tibia – 3, foot – 6. Simultaneous amputation of two lower limbs was observed in 2 patients. Amputation of upper limbs at shoulder level was observed in 3 patients, hand – 2, fingers – 15 patients. Among the reasons of limb amputations road traffic injuries occupied the leading position – 77.8 %. Combined injury (mechanical and thermal) was observed in 1 case – there was a burn of amputated limb. In 31 cases (59.6 %) there was complete amputation of a limb, incomplete – in 21 cases (40.4 %). Results. As a result of these tactics, only in 3 cases we had to do limb reamputation due to the inconsistency of the stump. In 22 patients for the conservation of sufficient length and the optimum shape of the stump the imposition of primary sutures was not made. At the stage of recovery of tissue covering the stump in 16 cases the closure of wound defects with simple split skin graft was fulfilled, 3 – with plastic by local tissues, 4 – islet flap on the peripheral stalk, 1 – plastic flat bridging flap, 20 operations were performed with tubular migratory classic flap. There were no complications in the postoperative period. Conclusions. The main principles in establishing the indications for reconstruction of large limb segments should be both critical attitude to the operation and strict individual approach to each patient based on the comprehensive evaluation of all the criteria.

The efficacy of construction of neourethra using a bladder anterior wall for treatment of female total urethral stricture or atresia

Objective To explore the efficacy of constructing the neourethra using a bladder anterior wall for the treatment of female total urethral stricture or atresia. Methods We retrospectively reviewed 11 female patients with total urethral stricture or oblitalition, who were underwent a procedure of reconstructive neourethra using a bladder anterior wall, from January 2009 to November 2015. Of the 11 patients , urethral stricture was associated with vesicovaginal fistula and a severe hydrocolpos in the proximal vagina because of vaginal anterior strictures or atresia in four girls. The mean age was 16 years (ranging 5-48 years) in all patients. The etiology was posttraumatic urethral injuries after pelvic fracture in 9 patients, radical urethral resection because of urethral cancer in 1 patient and congenital bladder exstrophy with an absent urethra in 1 patient. All patients underwent a procedure of neourethral construction under general anesthesia. The bladder anterior wall, which was about 2.0 to 2.5 cm in width and 4.0~4.5cm in length, was separated from bladder neck to middle partion of the anterior bladder wall. The bladder flap was tubularized around a 12-14 French catheter using continuous 4-0 polyglycolic acid sutures for the mucosa and interrupted sutures of 3-0 polyglycolic acid for the muscle. The tubularized flap was then flipped caudally to the site of the original external urethral meatus to form a new urethra. 4 patients with severe stenosis or oblitalition of the distal vagina underwent a procedure of vaginoplasty at same time, including island vulvar flaps enlarging vaginoplasty in two girls and reconstructive vaginal orifice using the proximal enlargedvagina wall in other two girls. Results There were no serious complications postoperatively. The catheter was removed 3~4 weeks after the operation. 7 patients were completely continent with excellent voiding, 3 patients had stress incontinence. One patient experienced dysuria. And the urethroscopy in this case showed that the mucosal prolapse was present at the 12 to 3 o'clock position on the neck of the bladder, which caused urinary obstruction. Endoscopic resection of the prolapsed mucosa was performed. The patient could easily void without incontinence after the operation. The patients were followed up a median of 38 months, (ranging 6-72 months). 2 patients experienced dysuria 3 and 4 months after operation, separatively. Examination showed that the mucosal prolapse was present at the position on the neck of the bladder in one patient and urethral meatal stenosis in another patient. The two patients were separatively underwent a procedure of endoscopic resection of the prolapsed mucosa and meatal urethroplasty, using vulvar flap. All of them could easily void without incontinence after the operation. Of the 3 patients with stress urinary incontinence, one underwent a procedure of TVT-O one year later, and after which continence was achieved with good voiding; the other two cases were awaiting for reoperation. Four cases of postoperative vaginal fluid disappeared with unobstructed micturition. Conclusions Female neo-urethral reconstruction using the bladder anterior wall flap was a reliable technique for the management of complete urethral stricture or obliteration. Key words: Female; Bladder wall flap; Urethra; Reconstruction

Continent Catheterizable Vesicostomy: An Alternative Surgical Modality for Pediatric Patients With Large Bladder Capacity

To present a modified technique and early outcomes of a continent catheterizable vesicostomy in pediatric patients with either flaccid neurogenic bladder or intractable voiding dysfunction and large capacity bladder. Six patients underwent the procedure from October 2014 to December 2015. A 4-cm Pfannenstiel incision was made, avoiding intraperitoneal dissection. After adequate mobilization, a 2-cm vertical flap at the dome of the bladder was identified and tubularized over a 12Fr catheter with 4-0 vicryl suture. The tubularized flap was then intussuscepted into the bladder with four 4-0 polydioxanone sutures, creating a continent mechanism. The catheterizable channel was then tunneled to the umbilicus, the channel ostomy matured, and the cystotomy closed in two layers. The median patient age was 8 (interquartile range [IQR] 12) years. All patients had urinary dysfunction requiring drainage from etiologies that included Eagle-Barrett syndrome (n = 2), Noonan syndrome (n = 1), Lennox-Gastaut syndrome (n = 1), and Spina bifida (n = 2). Median hospital length of stay was 8 (IQR 3) days. One patient had a superficial wound infection treated with antibiotics, and 1 patient required balloon dilation of the catheterizable channel at 3 months postoperatively, secondary to difficulty self-catheterizing. Five patients were successfully self-catheterizing at last follow-up. Median follow-up was 6 (IQR 5) months and there were no intra- or perioperative complications. Continent catheterizable vesicostomy is a novel technique for urinary drainage in patients with large bladder capacity that spares use of the appendix or ileum. Early results are encouraging, providing a catheterizable channel through the umbilicus without urinary leakage between catheterization.

Single-Staged Improved Tubularized Preputial/Penile Skin Flap Urethroplasty for Obliterated Anterior Urethral Stricture: Long-Term Results

Introduction: To present an improved tubularized flap (ITF) technique and report the outcome of single-stage urethroplasty using preputial/penile skin flaps (PSFs) for the treatment of obliterative anterior urethral strictures (AUSs). Materials and Methods: From January 2000 to June 2012, 42 cases of obliterative AUS (3-14 cm, mean 6.38 cm) with urethral plate unsalvageable were treated using PSF-ITF urethroplasty including longitudinal skin flap, circular island flap, L-flap, Q-flap. Patients were divided into 3 groups: pendulous urethral stricture (Group A), bulbar urethral stricture (Group B) and panurethral strictures (Group C). Patients were followed up by uroflowmetry, urethrography and ureteroscope when necessary. Results: The mean follow-up in these patients was 65 months (range 36 months-15 years). The primary success rates at 3-year follow-up were 75, 75 and 60% for Groups A, B and C, respectively. The overall success rates were 85, 83 and 70% with the remedial measure of a single visual internal urethrotomy at 3-year follow-up. A total 60% of the patients in the study completed more than 5 years of follow-up with no additional recurrence. Conclusions: Improved tubularized preputial/PSF urethroplasty with relatively high overall satisfaction is a novel technique for treatment of AUS when there is inadequate urethral plate or obliterative defects.