Duckett术式治疗儿童尿道下裂疗效及并发症防治
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摘要
目的探讨Duckett术式治疗儿童尿道下裂的疗效及其并发症的防治。方法对2009年4月-2017年5月就诊于我院小儿外科的23例复杂尿道下裂儿童行Duckett尿道成形术治疗,分析此术式治疗儿童尿道下裂的适应证及其并发症的防治。结果 23例接受Duckett术式治疗的尿道下裂患儿,年龄1~11岁,平均3.85岁;其中20例为初次手术,3例为再手术;均存在明显的阴茎下屈畸形或会阴部畸形。严重的阴茎下屈畸形合并阴茎阴囊转位15例(65.22%),阴茎下屈畸形复发、尿道瘘、尿道憩室、尿道结石及感染等难治性尿道下裂1例,合并尿道重复畸形1例,合并两性畸形1例。阴茎下屈畸形完全纠正后,海绵体尿道外口均移向近端,阴茎体近端型3例(13.04%),余20例属于阴茎阴囊型、阴囊型、会阴型等复杂近端型尿道下裂(86.96%);其中会阴型尿道下裂9例,4例行Duckett+Duplay术式,5例行Duckett术式。一期手术及修瘘术后成功治愈20例(86.96%)。结论 Duckett尿道成形术或Duckett+Duplay尿道成形术适用于儿童复杂近端型尿道下裂及合并其他畸形;阴茎下屈畸形未完全纠正、海绵体创面活动性渗血、Duckett皮瓣血运不良缺乏弹性及Duplay U型皮瓣裁剪过窄是术中应该注意的问题。
Objective To analyze indication of Duckett procedure for children suffered from hypospadias and management of its complications. Methods From June 2009 to May 2017, 23 children who suffered from complex hypospadias admitted to department of pediatric surgery underwent Duckett procedure to reconstruct their urethra. The indication of this procedure and the management of its complications were analyzed. Results Of the 23 patients receiving Duckett procedure, their age ranged from 1 to 11 years with an average of 3.85 years old. Twenty cases underwent primary urethral reconstruction, and 3 cases underwent secondary reconstruction. All patients presented with chordee or significant perineal malformation. Fifteen cases presented with severe chordee or penoscrotal transposition with a percentage of 65.22, one patient with refractory hypospadias presented with recurrent chordee, fistula, divertculum, stones and infection, one patient suffered from urethral duplication accompanied with hypospadias, one patient was characterized with intersex and hypospadias. Spongiosum urethral moved backwardly with the correction of chordee. New meatus located at proximal penile in 3 patients with a percentage of 13.04, while meatal sites moved backwardly to penoscrotal junction, intra-scotum and perineal respectively for the other 20 cases with a percentage of 86.96. Nine patients were classified as perineal hypospadias, four of them received Duckett + Duplay procedure and the other 5 cases underwent Duckett procedure. Twenty patients were cured through primary Duckett procedure or subsequent fistula repairs, with an eventual success rate of 86.96%. Conclusion Duckett procedure or Duckett + Duplay procedure should be carried out for patients with complicated proximal hypospadias with or without other related malformations. The following ones are contributing factors for complications which should be paid more attention to, including uncorrected chordee, active blood exudation of spongiosum wound, poor blood supply of prepuce island flap or penile skin island flap with less elasticity and too narrow U-shaped flap for Duplay perineal urethral reconstruction.
Objective To analyze indication of Duckett procedure for children suffered from hypospadias and management of its complications. Methods From June 2009 to May 2017, 23 children who suffered from complex hypospadias admitted to department of pediatric surgery underwent Duckett procedure to reconstruct their urethra. The indication of this procedure and the management of its complications were analyzed. Results Of the 23 patients receiving Duckett procedure, their age ranged from 1 to 11 years with an average of 3.85 years old. Twenty cases underwent primary urethral reconstruction, and 3 cases underwent secondary reconstruction. All patients presented with chordee or significant perineal malformation. Fifteen cases presented with severe chordee or penoscrotal transposition with a percentage of 65.22, one patient with refractory hypospadias presented with recurrent chordee, fistula, divertculum, stones and infection, one patient suffered from urethral duplication accompanied with hypospadias, one patient was characterized with intersex and hypospadias. Spongiosum urethral moved backwardly with the correction of chordee. New meatus located at proximal penile in 3 patients with a percentage of 13.04, while meatal sites moved backwardly to penoscrotal junction, intra-scotum and perineal respectively for the other 20 cases with a percentage of 86.96. Nine patients were classified as perineal hypospadias, four of them received Duckett + Duplay procedure and the other 5 cases underwent Duckett procedure. Twenty patients were cured through primary Duckett procedure or subsequent fistula repairs, with an eventual success rate of 86.96%. Conclusion Duckett procedure or Duckett + Duplay procedure should be carried out for patients with complicated proximal hypospadias with or without other related malformations. The following ones are contributing factors for complications which should be paid more attention to, including uncorrected chordee, active blood exudation of spongiosum wound, poor blood supply of prepuce island flap or penile skin island flap with less elasticity and too narrow U-shaped flap for Duplay perineal urethral reconstruction.
引文
1 Hendry WF.Rescent Advances in Urology/Andrology[M].New York:Churchill-Livingstone,1980:279-290.
2 Gillenwater JY,Grayhack JT,Howards SS,et al.Adult and Pediatric Urology[M].3rd ed.Chicago:Yearbook Medical,1996:2572-2574.
3 张潍平,孙宁,黄澄如,等.尿道下裂手术方法选择再认识[J].临床儿科杂志,2004,22(6):347-349.
4 韩文文,张潍平,孙宁,等.小儿泌尿外科医师尿道下裂学习曲线探讨[J].继续医学教育,2016,30(3):51-52.
5 孙宁.尿道下裂修复手术问题与再认识[J].中华小儿外科杂志,2015,36(3):161-162.
6 黄澄如.尿道下裂治疗现状[J].中华小儿外科杂志,1997,18(1):1-2.
7 张潍平,黄澄如,白继武,等.重度尿道下裂的手术修复[J].中华小儿外科杂志,1997,18(1):28-29.
8 Tiryaki T.Combination of tubularized island flap and ventral skin flap techniques in single-stage correction of severe proximal hypospadias[J].Urol Int,2010,84(3):269-274.
9 Pinke LA,Rathbun SR,Husmann DA,et al.Penoscrotal transposition:review of 53 patients[J].J Urol,2001,166(5):1865-1868.
10 Ciftci AO,Senocak ME,Buyukpamukcu N,et al.Abnormal prostatic utricle configuration in hypospadias and intersex patients[J].Eur J Pediatr Surg,1999,9(3):167-172.
11 张潍平,孙宁,白继武,等.尿道下裂带蒂岛状皮瓣尿道成形术成功率的多因素分析及实验研究[J].中华小儿外科杂志,1992,13(3):167-168.
12 Ahmed M,Alsaid A.Is combined inner preputial inlay graft with tubularized incised plate in hypospadias repair worth doing?[J].J Pediatr Urol,2015,11(4):229.e221-224.
13 Díaz Naranjo S,Crespo Martínez L,García-Matres MJ,et al.Primary hypospadias[J].Arch Esp Urol,2014,67(1):46-53.
14 Arnaud A,Ferdynus C,Harper L.Can separation of the scrotal sac in proximal hypospadias reliably predict the need for urethral plate transection[J].J Pediatr Urol,2016,12(2):121.
15 Bhat A,Bhat M,Kumar V,et al.Comparison of variables affecting the surgical outcomes of tubularized incised plate urethroplasty in adult and pediatric hypospadias[J].J Pediatr Urol,2016,12(2):108-101.
16 Ozcan R,Emre S,Kendigelen P,et al.Results of a Two-stage Technique for Treatment of Proximal Hypospadias with Severe Curvature:Creation of a Urethral Plate Using a Vascularized Preputial Island Flap[J].Urol J,2016,13(2):2629-2634.
17 Zhiqiang F,Zhonghua L,Xuejun H,et al.Urethroplasty in the distal penile segment using flap for the staged correction of severe hypospadias[J].Zhonghua zhengxing waike zazhi,2015,31(6):414-418.
18 Zhang S,Zhou C,Li F,et al.Scrotal-Septal Fasciocutaneous Flap Used as a Multifunctional Coverage for Prior Failed Hypospadias Repair[J].Urol Int,2016,96(3):255-259.
19 Pippi Salle JL,Sayed S,Salle A,et al.Proximal hypospadias:A persistent challenge.Single institution outcome analysis of three surgical techniques over a 10-year period[J].J Pediatr Urol,2016,12(1):28.e21-27.
20 Xue JD,Xie H,Fu Q,et al.Single-Staged Improved Tubularized Preputial/Penile Skin Flap Urethroplasty for Obliterated Anterior Urethral Stricture:Long-Term Results[J].Urol Int,2016,96(2):231-237.
21 肖元宏,刘贵麟,刘洲禄.尿道外口前移阴茎头成形术治疗儿童尿道下裂5例[J].解放军医学院学报,2016,37(10):1106-1110.
22 肖元宏,刘贵麟,刘洲禄.Onlay岛状皮瓣尿道成形术治疗儿童尿道下裂适应证及并发症防治[J].解放军医学院学报,2016,37(11):1152-1154.
23 黄澄如.小儿泌尿外科学[M].济南:山东科学技术出版社,1995:180-202,205-206.
24 白继武,黄澄如,梁若馨,等.小儿尿道重复畸形[J].中华小儿外科杂志,1995,16(1):20-22.
25 Bouhafs A,Abarchi H,Belkacem R,et al.Anterior urethral duplication in a male child.A case report[J].Ann Urol(Paris),2002,36(2):146-149.
26 Deniz N,Kirac M,Camtosun A,et al.Repair of hypospadiac urethral duplication with dismembered urethroplasty[J].Urol Int,2008,80(1):105-107.
27 Kaefer M,Diamond D,Hendren WH,et al.The incidence of intersexuality in children with cryptorchidism and hypospadias:stratification based on gonadal palpability and meatal position[J].J Urol,1999,162(3 Pt 2):1003-1006.
28 Ahmeti H,Kolgeci S,Arifi H,et al.Clinical dilemmas and surgical treatment of penoscrotal,scrotal and perineal hypospadias[J].Bosn J Basic Med Sci,2009,9(3):229-234.
29 Vidal I,Gorduza DB,Haraux E,et al.Surgical options in disorders of sex development(dsd)with ambiguous genitalia[J].Best Pract Res Clin Endocrinol Metab,2010,24(2):311-324.
30 Westenfelder M.Modern concepts in the treatment of intersexuality[J].Urologe A,2004,43(4):379-393.
31 Soutis M,Papandreou E,Mavridis G,et al.Multiple failed urethroplasties:definitive repair with the Duckett island-flap technique[J].J Pediatr Surg,2003,38(11):1633-1636.
2 Gillenwater JY,Grayhack JT,Howards SS,et al.Adult and Pediatric Urology[M].3rd ed.Chicago:Yearbook Medical,1996:2572-2574.
3 张潍平,孙宁,黄澄如,等.尿道下裂手术方法选择再认识[J].临床儿科杂志,2004,22(6):347-349.
4 韩文文,张潍平,孙宁,等.小儿泌尿外科医师尿道下裂学习曲线探讨[J].继续医学教育,2016,30(3):51-52.
5 孙宁.尿道下裂修复手术问题与再认识[J].中华小儿外科杂志,2015,36(3):161-162.
6 黄澄如.尿道下裂治疗现状[J].中华小儿外科杂志,1997,18(1):1-2.
7 张潍平,黄澄如,白继武,等.重度尿道下裂的手术修复[J].中华小儿外科杂志,1997,18(1):28-29.
8 Tiryaki T.Combination of tubularized island flap and ventral skin flap techniques in single-stage correction of severe proximal hypospadias[J].Urol Int,2010,84(3):269-274.
9 Pinke LA,Rathbun SR,Husmann DA,et al.Penoscrotal transposition:review of 53 patients[J].J Urol,2001,166(5):1865-1868.
10 Ciftci AO,Senocak ME,Buyukpamukcu N,et al.Abnormal prostatic utricle configuration in hypospadias and intersex patients[J].Eur J Pediatr Surg,1999,9(3):167-172.
11 张潍平,孙宁,白继武,等.尿道下裂带蒂岛状皮瓣尿道成形术成功率的多因素分析及实验研究[J].中华小儿外科杂志,1992,13(3):167-168.
12 Ahmed M,Alsaid A.Is combined inner preputial inlay graft with tubularized incised plate in hypospadias repair worth doing?[J].J Pediatr Urol,2015,11(4):229.e221-224.
13 Díaz Naranjo S,Crespo Martínez L,García-Matres MJ,et al.Primary hypospadias[J].Arch Esp Urol,2014,67(1):46-53.
14 Arnaud A,Ferdynus C,Harper L.Can separation of the scrotal sac in proximal hypospadias reliably predict the need for urethral plate transection[J].J Pediatr Urol,2016,12(2):121.
15 Bhat A,Bhat M,Kumar V,et al.Comparison of variables affecting the surgical outcomes of tubularized incised plate urethroplasty in adult and pediatric hypospadias[J].J Pediatr Urol,2016,12(2):108-101.
16 Ozcan R,Emre S,Kendigelen P,et al.Results of a Two-stage Technique for Treatment of Proximal Hypospadias with Severe Curvature:Creation of a Urethral Plate Using a Vascularized Preputial Island Flap[J].Urol J,2016,13(2):2629-2634.
17 Zhiqiang F,Zhonghua L,Xuejun H,et al.Urethroplasty in the distal penile segment using flap for the staged correction of severe hypospadias[J].Zhonghua zhengxing waike zazhi,2015,31(6):414-418.
18 Zhang S,Zhou C,Li F,et al.Scrotal-Septal Fasciocutaneous Flap Used as a Multifunctional Coverage for Prior Failed Hypospadias Repair[J].Urol Int,2016,96(3):255-259.
19 Pippi Salle JL,Sayed S,Salle A,et al.Proximal hypospadias:A persistent challenge.Single institution outcome analysis of three surgical techniques over a 10-year period[J].J Pediatr Urol,2016,12(1):28.e21-27.
20 Xue JD,Xie H,Fu Q,et al.Single-Staged Improved Tubularized Preputial/Penile Skin Flap Urethroplasty for Obliterated Anterior Urethral Stricture:Long-Term Results[J].Urol Int,2016,96(2):231-237.
21 肖元宏,刘贵麟,刘洲禄.尿道外口前移阴茎头成形术治疗儿童尿道下裂5例[J].解放军医学院学报,2016,37(10):1106-1110.
22 肖元宏,刘贵麟,刘洲禄.Onlay岛状皮瓣尿道成形术治疗儿童尿道下裂适应证及并发症防治[J].解放军医学院学报,2016,37(11):1152-1154.
23 黄澄如.小儿泌尿外科学[M].济南:山东科学技术出版社,1995:180-202,205-206.
24 白继武,黄澄如,梁若馨,等.小儿尿道重复畸形[J].中华小儿外科杂志,1995,16(1):20-22.
25 Bouhafs A,Abarchi H,Belkacem R,et al.Anterior urethral duplication in a male child.A case report[J].Ann Urol(Paris),2002,36(2):146-149.
26 Deniz N,Kirac M,Camtosun A,et al.Repair of hypospadiac urethral duplication with dismembered urethroplasty[J].Urol Int,2008,80(1):105-107.
27 Kaefer M,Diamond D,Hendren WH,et al.The incidence of intersexuality in children with cryptorchidism and hypospadias:stratification based on gonadal palpability and meatal position[J].J Urol,1999,162(3 Pt 2):1003-1006.
28 Ahmeti H,Kolgeci S,Arifi H,et al.Clinical dilemmas and surgical treatment of penoscrotal,scrotal and perineal hypospadias[J].Bosn J Basic Med Sci,2009,9(3):229-234.
29 Vidal I,Gorduza DB,Haraux E,et al.Surgical options in disorders of sex development(dsd)with ambiguous genitalia[J].Best Pract Res Clin Endocrinol Metab,2010,24(2):311-324.
30 Westenfelder M.Modern concepts in the treatment of intersexuality[J].Urologe A,2004,43(4):379-393.
31 Soutis M,Papandreou E,Mavridis G,et al.Multiple failed urethroplasties:definitive repair with the Duckett island-flap technique[J].J Pediatr Surg,2003,38(11):1633-1636.