Monday, April 23, 2012

Koyanagi repair



Use of the Koyanagi repair is determined from the outset of the operation based on the surgeons impression that VC will lead to urethral plate excision. The Koyanagi repair updates the Russell operation (Russell, 1900), primarily by maintaining blood supply to the flaps as illustrated in Figure 1. These flaps are brought together ventrally, sewn into a single strip, and then tubularized proximally to distally.





Figure 1: Koyanagi flap. A, Proposed lines of incisions to create flap. B, The flap can be divided into two wings as shown or maintained in one piece with a central buttonhole to transpose it ventrally. C, The urethral plate in the center of the flap is dissected from the corpora to near the meatus, and the glanular portion of the plate is excised as glans wings are made. D, Inner flap margins are reapproximated, and excess flap skin is excised. E, The outer margins are closed to complete tubularization using 7-0 polyglactin or polydioxanone subepithelial interrupted or running sutures. Glansplasty and skin closure are as described for other preputial flaps.

Outcomes: Proponents offer varied opinions for managing the dartos vascular pedicle to the lateral skin flaps. Koyanagi and colleagues (1994) split the contiguous flap into a Y at the 12-oclock position. Others attribute complications to devascularization of the distal region and instead maintain the loop, passing the glans dorsally through a 12-oclock buttonhole in the dartos pedicle. Alternatively, in the largest reported series the pedicle was removed from the distal 2 cm of the flap, which was treated as a tubularized graft (Sugita et al, 2001).
Complications: 47%
Fistulas: 15/77
Meatal Stenosis: 0
Stricture: 6/77
Dehiscence: 12/77
Diverticulum: 0
Recurrent VC: 0

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