i ¸
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SURGEON S WORKSHO_
ABDOMINOPLASTY COMBINED WITH LOWER URINARY TRACT SURGERY DANIEL YACHIA, M.D. From the Department of Urology, Hillel Yaffe Medical Center, Hadera, Israel
Abdominoplasties combined with other surgical procedures are not common. However, women after their fourth and fifth decades with lax abdominal walls or scars from previous surgical procedures occasionally inquire about the possibility of combining some urologic surgery with abdominoplasty. Combining a medically indicated procedure with a surgery that is generally considered cosmetic, is controversial. Although some gynecologic procedures lend themselves to combined procedures, I-3 most reports in the literature are about combinations of abdominoplastics with other eosmetie procedures performed by the same plastic surgeon. 4 However, there are some reports on abdominoplasties combined with other surgical procedures. 5,7 To our knowledge none has been reported combined with urologic surgery. We present a patient in whom we combined a bilateral transtrigonal ureteral advancement with an abdominoplasty for purely surgical reasons.
eetomy and oophoreetomy for benign o v a r i ~ tumor. The alternatives we had were t w o : ~ proceed with the urologic operation and l e ~ the abdominal problem for a future o p e r a t i ~ with the risk of wound infection; or to e o m b i ~ the urologic procedure with abdominoplas[y~ We elected to perform the latter proeedurei N Technique Holding and lifting the skinfolds with t ' ~ strong sutures, a transverse bow-like i n c i s J ~ was made between the spina iliaca anteriol ~ perior, running along the pubic hair line ( i ' ~ ~ne a). A second transverse incision a e x t e n d i n g from the mid umbilicopl N
Case Report A sixty-six-year-old woman was seen because of recurring urinary tract infections accompanied with fever and chills and deteriorating renal function. Urologic investigation revealed grade IV vesicoureteral reflux. She was scheduled for a transtrigonal ureteral advancement. Patient's height was 1.52 m and weight 82 kg. During the last year she voluntarily had lost more than 20 kg resulting in a large abdominal skin apron that extended onto the back, eireumventing the thighs. When standing, the skin folds covered the upper third of her thighs, and when lying down the lax skin overflowed from both sides of the examining table. She had a low midline abdominal sear from a previous hyster266
b S 15crr
FmURE 1. Incision lines: a, b, c, d. (Key: s iliaca anterior superior; t = iliac tuberosity~il umbilicus; shaded area: removed redundan and ]at.)
UROLOGY
/ MARCH 1991 / VOLUME XXXVII, NU : ~ ; i ! ~
u
/'1',
\
/ ~
FIGURE 2.
Closure lines.
reaching the iliae tuberosimding about 15 em higher ,rle with the apex pointing ated (Fig. 1, lines c-d) on dant skin and fat were disLbdominal fascia. The bor[g skin were covered with e urologic procedure was tder and abdominal fascia a eystostomy catheter, two retropubie Penrose drain. abdominal skin and its fat ~eeted from the fascia until ower incision line. The trivere undermined and toothe saggifig folds of the (Fig. 2). The w o u n d was ~nd the subcutaneous area drainage systems, under and the abdominal flap Io "dog ears" remained afours of the hips were aclal undermining made no 'asts were used postopera:hing exercises and leg mo; soon as the patient was thromboembolic eomplithe patient was mobilized tair, and in the afternoon lr in the ward. 9eriod was uneventful un~tibiotie coverage. No he-
/ MARCH 1991 / VOLUME XXXVII, NUMBER 3
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FIGURE 3. Drainage points: (I) Areas drained with close drainage system. (2) Penrose, draining Betzius space. (3) Suprapubic cystostomy catheter. (4) Right and left ureteral splints. matoma, seroma, or skin necrosis developed, except for 1 cm 2 necrosis at the apex of the left triangle that healed spontaneously. The decreased sensation in the lower abdominal skin that developed after surgery disappeared progressively. Hadera 38101 Israel References 1. Kelly HA: Report of gynecological cases. Case 3. Excessive growth of fat, Bull Johns Hopkins Hosp 10:196 (1899). 2. Grazer FM, and Klingbeil JR: Body Image: A Surgical Perspective, St Louis, CV Mosby, 1980, pp 63-237. 3. Grazer FM: Abdominoplasty, Plast Reconstr Surg 51:617 (1973). 4. Perry AW: Abdominoplasty combined with total abdominal hysterectomy, Ann Plast Surg 16:121 (1986), 5. Pitanguy I: Abdominal lipectomy. An approach to it through an analysis of 300 consecutive cases, Plast Reeonstr Surg 40:384 (1967). 6. Savage RC: Abdominoplasty combined with other surgical procedures, Plast Reeonstr Surg 70:437 (1982). 7. Savage RC: Abdominoplasty following gastrointestinal bypass surgery, Plast Reconstr Surg 71:500 (1983}.
267
?
SURGEON S WORKSHO_
ABDOMINOPLASTY COMBINED WITH LOWER URINARY TRACT SURGERY DANIEL YACHIA, M.D. From the Department of Urology, Hillel Yaffe Medical Center, Hadera, Israel
Abdominoplasties combined with other surgical procedures are not common. However, women after their fourth and fifth decades with lax abdominal walls or scars from previous surgical procedures occasionally inquire about the possibility of combining some urologic surgery with abdominoplasty. Combining a medically indicated procedure with a surgery that is generally considered cosmetic, is controversial. Although some gynecologic procedures lend themselves to combined procedures, I-3 most reports in the literature are about combinations of abdominoplastics with other eosmetie procedures performed by the same plastic surgeon. 4 However, there are some reports on abdominoplasties combined with other surgical procedures. 5,7 To our knowledge none has been reported combined with urologic surgery. We present a patient in whom we combined a bilateral transtrigonal ureteral advancement with an abdominoplasty for purely surgical reasons.
eetomy and oophoreetomy for benign o v a r i ~ tumor. The alternatives we had were t w o : ~ proceed with the urologic operation and l e ~ the abdominal problem for a future o p e r a t i ~ with the risk of wound infection; or to e o m b i ~ the urologic procedure with abdominoplas[y~ We elected to perform the latter proeedurei N Technique Holding and lifting the skinfolds with t ' ~ strong sutures, a transverse bow-like i n c i s J ~ was made between the spina iliaca anteriol ~ perior, running along the pubic hair line ( i ' ~ ~ne a). A second transverse incision a e x t e n d i n g from the mid umbilicopl N
Case Report A sixty-six-year-old woman was seen because of recurring urinary tract infections accompanied with fever and chills and deteriorating renal function. Urologic investigation revealed grade IV vesicoureteral reflux. She was scheduled for a transtrigonal ureteral advancement. Patient's height was 1.52 m and weight 82 kg. During the last year she voluntarily had lost more than 20 kg resulting in a large abdominal skin apron that extended onto the back, eireumventing the thighs. When standing, the skin folds covered the upper third of her thighs, and when lying down the lax skin overflowed from both sides of the examining table. She had a low midline abdominal sear from a previous hyster266
b S 15crr
FmURE 1. Incision lines: a, b, c, d. (Key: s iliaca anterior superior; t = iliac tuberosity~il umbilicus; shaded area: removed redundan and ]at.)
UROLOGY
/ MARCH 1991 / VOLUME XXXVII, NU : ~ ; i ! ~
u
/'1',
\
/ ~
FIGURE 2.
Closure lines.
reaching the iliae tuberosimding about 15 em higher ,rle with the apex pointing ated (Fig. 1, lines c-d) on dant skin and fat were disLbdominal fascia. The bor[g skin were covered with e urologic procedure was tder and abdominal fascia a eystostomy catheter, two retropubie Penrose drain. abdominal skin and its fat ~eeted from the fascia until ower incision line. The trivere undermined and toothe saggifig folds of the (Fig. 2). The w o u n d was ~nd the subcutaneous area drainage systems, under and the abdominal flap Io "dog ears" remained afours of the hips were aclal undermining made no 'asts were used postopera:hing exercises and leg mo; soon as the patient was thromboembolic eomplithe patient was mobilized tair, and in the afternoon lr in the ward. 9eriod was uneventful un~tibiotie coverage. No he-
/ MARCH 1991 / VOLUME XXXVII, NUMBER 3
~
,'..
4 e4 ~
~
"" ~" . . . .
~
ss
,I,,
FIGURE 3. Drainage points: (I) Areas drained with close drainage system. (2) Penrose, draining Betzius space. (3) Suprapubic cystostomy catheter. (4) Right and left ureteral splints. matoma, seroma, or skin necrosis developed, except for 1 cm 2 necrosis at the apex of the left triangle that healed spontaneously. The decreased sensation in the lower abdominal skin that developed after surgery disappeared progressively. Hadera 38101 Israel References 1. Kelly HA: Report of gynecological cases. Case 3. Excessive growth of fat, Bull Johns Hopkins Hosp 10:196 (1899). 2. Grazer FM, and Klingbeil JR: Body Image: A Surgical Perspective, St Louis, CV Mosby, 1980, pp 63-237. 3. Grazer FM: Abdominoplasty, Plast Reconstr Surg 51:617 (1973). 4. Perry AW: Abdominoplasty combined with total abdominal hysterectomy, Ann Plast Surg 16:121 (1986), 5. Pitanguy I: Abdominal lipectomy. An approach to it through an analysis of 300 consecutive cases, Plast Reeonstr Surg 40:384 (1967). 6. Savage RC: Abdominoplasty combined with other surgical procedures, Plast Reeonstr Surg 70:437 (1982). 7. Savage RC: Abdominoplasty following gastrointestinal bypass surgery, Plast Reconstr Surg 71:500 (1983}.
267
