儿童复杂近端型尿道下裂术后尿道狭窄的病理改变及治疗
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摘要
目的探讨儿童复杂近端型尿道下裂术后尿道狭窄的病理改变及治疗。方法对2008年10月-2017年6月就诊于我院小儿外科的8例尿道下裂术后尿道狭窄病例进行回顾性分析。结果 8例患儿初次就诊于我院时年龄为2~11岁,平均4.85岁,初均接受皮瓣卷管尿道成形术。初次手术前阴茎型尿道下裂4例,阴茎阴囊型尿道下裂1例,会阴型尿道下裂3例。8例复杂近端型尿道下裂术后尿道狭窄的病理分型为Ⅰ型(尿道外口狭窄继发尿瘘)、Ⅱ型(尿道节段性狭窄)、Ⅲ型(尿道外口狭窄、尿瘘及憩室共存)、Ⅳ型(尿道外口狭窄、尿道狭窄、继发尿瘘及尿道扩张),各占2例。Ⅰ型尿道狭窄通过尿道外口扩张,Mathieu阴茎头尿道成形术治愈;Ⅱ型尿道狭窄通过海绵体尿道端端吻合术或狭窄段纵形切开尿管置入支撑治疗治愈;Ⅲ型尿道狭窄通过分期手术治疗,即一期完成憩室消除、阴茎头尿道板成形、尿瘘修补术,二期完成阴茎头尿道成形术;Ⅳ型尿道狭窄通过分期手术治疗,即一期实施瘢痕处尿道造口,远端尿道尿管支撑治疗,待瘢痕软化后二期实施尿道造口皮瓣覆盖修补及阴茎头尿道成形术。6例治愈者自初次手术至治愈的时间为14~62个月,平均为30.17个月;接受治疗的次数为2~9次,平均为5次。结论儿童尿道下裂术后尿道狭窄多发生于复杂近端型尿道下裂、初次手术采用皮瓣卷管尿道成形术者。消除狭窄环或狭窄节段后,以阴茎腹侧或背侧血运较好、具有一定延展性的皮瓣修补尿道是合适的处理方式。
Objective To study the pathologic characteristics of urethral stricture after correction of complex proximal hypospadias in children and its treatment. Methods Clinical data about 8 children who admitted to our department for their urethral stricture after operations of complex proximal hypospadias from October 2008 to June 2017 were analyzed retrospectively. Results The age of 8 children at first admission ranged from 2 years to 11 years, with a mean age of 4.85 years. All of them received flap tube urethroplasty as their primary procedures. Before primary operations, there were 4 cases with penile type hyposadias, one case with penoscrotal type and 3 cases with perineal type. The pathology of urethral stricture were classified as: typeⅠ(2 cases): meatal stricture followed by fistula, typeⅡ(2 cases): segmental stricture of urethra, typeⅢ(2 cases): coexistence of meatal stricture, fistula and diverticulum, and typeⅣ(2 cases): meatal stricture and urethral stricture followed by fistula and urethral dilatation. Patients with typeⅠstricture were cured by meatal dilation or Mathieu procedure of glan urethroplasty. Cases with typeⅡstricture were cured by end to end spongiosum urethral anastomosis or incision of the stricture and insertion of urethral tube. Cases with type Ⅲstricture received two-stage repair, with primarily diverticulum excision, glan urethral plate palsty and fistula repair, and glan urethral plasty secondarily. Cases with type Ⅳ stricture also received two-stage repair, with primarily scared urethral ostomy and urethral tube insertion of the distal urethral for dilation, and secondary flap repair for the ostomy and glan urethral plasty after scar softened completely. Length of treatment for 6 cured patients ranged from 14 months to 62 months with a mean value of 30.17 months. Frequency for treatment ranged from 2 to 9 times with a mean value of 5 times. Conclusion Postoperative urethral stricture most commonly occurrs in children suffered from complex proximal hypospadias who have received flap tube as their primary urethroplasty. Longitudinal incision of the stricture loop or segmental stricture, followed by urethroplasty using ventral or dorsal penile skin flap with relatively good blood supply and flexibility to replace the unhealthy urethral are the appropriate option for cure.
Objective To study the pathologic characteristics of urethral stricture after correction of complex proximal hypospadias in children and its treatment. Methods Clinical data about 8 children who admitted to our department for their urethral stricture after operations of complex proximal hypospadias from October 2008 to June 2017 were analyzed retrospectively. Results The age of 8 children at first admission ranged from 2 years to 11 years, with a mean age of 4.85 years. All of them received flap tube urethroplasty as their primary procedures. Before primary operations, there were 4 cases with penile type hyposadias, one case with penoscrotal type and 3 cases with perineal type. The pathology of urethral stricture were classified as: typeⅠ(2 cases): meatal stricture followed by fistula, typeⅡ(2 cases): segmental stricture of urethra, typeⅢ(2 cases): coexistence of meatal stricture, fistula and diverticulum, and typeⅣ(2 cases): meatal stricture and urethral stricture followed by fistula and urethral dilatation. Patients with typeⅠstricture were cured by meatal dilation or Mathieu procedure of glan urethroplasty. Cases with typeⅡstricture were cured by end to end spongiosum urethral anastomosis or incision of the stricture and insertion of urethral tube. Cases with type Ⅲstricture received two-stage repair, with primarily diverticulum excision, glan urethral plate palsty and fistula repair, and glan urethral plasty secondarily. Cases with type Ⅳ stricture also received two-stage repair, with primarily scared urethral ostomy and urethral tube insertion of the distal urethral for dilation, and secondary flap repair for the ostomy and glan urethral plasty after scar softened completely. Length of treatment for 6 cured patients ranged from 14 months to 62 months with a mean value of 30.17 months. Frequency for treatment ranged from 2 to 9 times with a mean value of 5 times. Conclusion Postoperative urethral stricture most commonly occurrs in children suffered from complex proximal hypospadias who have received flap tube as their primary urethroplasty. Longitudinal incision of the stricture loop or segmental stricture, followed by urethroplasty using ventral or dorsal penile skin flap with relatively good blood supply and flexibility to replace the unhealthy urethral are the appropriate option for cure.
引文
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2 Yang Y,Yu B,Sun D,et al.The dose-dependence biological effect of laser fluence on rabbit fibroblasts derived from urethral scar[J].Lasers Med Sci,2015,30(3):1019-1029.
3 黄翔,申吉泓,李虹,等.尿道瘢痕成纤维细胞培养及药物对其生长的影响[J].华西医科大学学报,2002,33(2):220-222.
4 莫家骢,王胜义.肤康片防治尿道吻合术后瘢痕狭窄的实验研究[J].中药材,2004,27(7):511-513.
5 Uemura S,Hutson JM,Woodward AA,et al.Balanitis xerotica obliterans with urethral stricture after hypospadias repair[J].Pediatr Surg Int,2000,16(1-2):144-145.
6 薛文勇,齐进春,杨彩云,等.改良尿道板重建卷管尿道成形术结合睾丸鞘膜覆盖治疗重度尿道下裂[J].中华整形外科杂志,2014,30(6):436-438.
7 Mosharafa AA,Agbo-Panzo D,Priso R,et al.Repair of hypospadias:the effect of urethral plate configuration on the outcome of DuplaySnodgrass repair[J].Prog Urol,2009,19(7):507-510.
8 Tuygun C,Bakirtas H,Gucuk A,et al.Uroflow findings in older boys with tubularized incised-plate urethroplasty[J].Urol Int,2009,82(1):71-76.
9 Anheuser P,Schmidt S,Steffens JA.Meatal stenosis.Mundane problem or surgical challenge?[J].Urologe A,2010,49(6):714,716-9.
10 Ardelt PU,Glaser T,Schoenthaler M,et al.Glandular resection and central embedding in hypospadias repair--a novel modification of the Barcat technique[J].J Pediatr Surg,2012,47(5):1032-1037.
11 Palminteri E,Berdondini E,Verze P,et al.Contemporary urethral stricture characteristics in the developed world[J].Urology,2013,81(1):191-196.
12 Bleustein CB,Esposito MP,Soslow RA,et al.Mechanism of healing following the Snodgrass repair[J].J Urol,2001,165(1):277-279.
13 Lopes JF,Schned A,Ellsworth PI,et al.Histological analysis of urethral healing after tubularized incised plate urethroplasty[J].J Urol,2001,166(3):1014-1017.
14 Taneli F,Ulman C,Genc A,et al.Biochemical analysis of urethral collagen content after tubularized incised plate urethroplasty:an experimental study in rabbits[J].Urol Res,2004,32(3):219-222.
15 Beintker M,Vogt B,Schubert J,et al.Urethroplasty with tissue matrix.Microsurgical animal experiments with small intestinal submucosa[J].Urologe A,2007,46(9):1236-1237.
16 Eassa W,He X,El-Sherbiny M.How much does the midline incision add to urethral diameter after tubularized incised plate urethroplasty?An experimental animal study[J].J Urol,2011,186(4 Suppl):1625-1629.
17 谢向辉,黄澄如,白继武.尿道下裂尿道成形术后尿道狭窄的处理[J].中华泌尿外科杂志,2000,21(4):232-234.
18 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.
19 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.
2 Yang Y,Yu B,Sun D,et al.The dose-dependence biological effect of laser fluence on rabbit fibroblasts derived from urethral scar[J].Lasers Med Sci,2015,30(3):1019-1029.
3 黄翔,申吉泓,李虹,等.尿道瘢痕成纤维细胞培养及药物对其生长的影响[J].华西医科大学学报,2002,33(2):220-222.
4 莫家骢,王胜义.肤康片防治尿道吻合术后瘢痕狭窄的实验研究[J].中药材,2004,27(7):511-513.
5 Uemura S,Hutson JM,Woodward AA,et al.Balanitis xerotica obliterans with urethral stricture after hypospadias repair[J].Pediatr Surg Int,2000,16(1-2):144-145.
6 薛文勇,齐进春,杨彩云,等.改良尿道板重建卷管尿道成形术结合睾丸鞘膜覆盖治疗重度尿道下裂[J].中华整形外科杂志,2014,30(6):436-438.
7 Mosharafa AA,Agbo-Panzo D,Priso R,et al.Repair of hypospadias:the effect of urethral plate configuration on the outcome of DuplaySnodgrass repair[J].Prog Urol,2009,19(7):507-510.
8 Tuygun C,Bakirtas H,Gucuk A,et al.Uroflow findings in older boys with tubularized incised-plate urethroplasty[J].Urol Int,2009,82(1):71-76.
9 Anheuser P,Schmidt S,Steffens JA.Meatal stenosis.Mundane problem or surgical challenge?[J].Urologe A,2010,49(6):714,716-9.
10 Ardelt PU,Glaser T,Schoenthaler M,et al.Glandular resection and central embedding in hypospadias repair--a novel modification of the Barcat technique[J].J Pediatr Surg,2012,47(5):1032-1037.
11 Palminteri E,Berdondini E,Verze P,et al.Contemporary urethral stricture characteristics in the developed world[J].Urology,2013,81(1):191-196.
12 Bleustein CB,Esposito MP,Soslow RA,et al.Mechanism of healing following the Snodgrass repair[J].J Urol,2001,165(1):277-279.
13 Lopes JF,Schned A,Ellsworth PI,et al.Histological analysis of urethral healing after tubularized incised plate urethroplasty[J].J Urol,2001,166(3):1014-1017.
14 Taneli F,Ulman C,Genc A,et al.Biochemical analysis of urethral collagen content after tubularized incised plate urethroplasty:an experimental study in rabbits[J].Urol Res,2004,32(3):219-222.
15 Beintker M,Vogt B,Schubert J,et al.Urethroplasty with tissue matrix.Microsurgical animal experiments with small intestinal submucosa[J].Urologe A,2007,46(9):1236-1237.
16 Eassa W,He X,El-Sherbiny M.How much does the midline incision add to urethral diameter after tubularized incised plate urethroplasty?An experimental animal study[J].J Urol,2011,186(4 Suppl):1625-1629.
17 谢向辉,黄澄如,白继武.尿道下裂尿道成形术后尿道狭窄的处理[J].中华泌尿外科杂志,2000,21(4):232-234.
18 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.
19 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.