口腔黏膜背侧移植结合阴茎带蒂皮瓣腹侧覆盖治疗阴茎部尿道狭窄
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摘要
目的:总结口腔黏膜背侧游离移植结合阴茎带蒂皮瓣腹侧覆盖尿道扩大成形术治疗阴茎部尿道狭窄的临床效果及经验。方法:选择北京积水潭医院泌尿外科2015年11月至2018年10月采用口腔黏膜背侧游离移植结合阴茎带蒂皮瓣腹侧覆盖尿道扩大成形术治疗阴茎部尿道狭窄患者22例的病例资料进行回顾性分析。所有患者均无术前尿瘘等合并症,均为单纯性单处阴茎部尿道狭窄,其中医源性狭窄14例(63.6%)、感染性狭窄2例(9.1%)、特发性狭窄6例(27.3%)。术中均从腹侧纵行切开尿道狭窄段,先采用游离口腔黏膜做狭窄段背侧嵌式修补,腹侧采用纵行阴茎带蒂皮瓣(Orandi皮瓣)覆盖修补,留置16F或14F硅胶尿管,3周后拔除尿管并行尿道造影及膀胱镜检查。术后最大尿流率≥15 mL/s且不需要尿道扩张等外科干预可视为手术成功。结果:本组患者年龄平均52.6(18～73)岁。患者尿道狭窄均位于前尿道阴茎部,长度平均5.3(2.5～10.0) cm,术前平均最大尿流率6.7 mL/s。口腔黏膜取材长度平均5.5(3.2～10.5) cm,阴茎皮瓣长度平均6.0(3.5～11.0) cm。手术时间平均225(150～420) min,术中平均估计失血量53(20.0～110.0) mL。采用颊黏膜19例(86.4%),舌黏膜3例(13.6%),其中双侧颊黏膜取材5例(22.7%)。平均随访20.5(5～51)个月,术后6个月平均最大尿流率21.2(15～32) mL/s。术后尿瘘形成1例、再狭窄2例,手术成功率为81.8%(18/22),2例再狭窄患者1例再次行尿道成形术后治愈,另1例行定期尿道扩张治疗。术后感染2例,表现为尿道口脓液溢出、阴茎肿胀,对症处理后治愈。局部皮肤坏死1例,给予保守治疗成功。尿瘘患者行瘘修补术后治愈。结论:口腔黏膜背侧游离移植结合阴茎带蒂皮瓣腹侧覆盖尿道扩大成形术治疗阴茎部尿道狭窄22例平均随访20.5个月,手术成功率为81.8%,临床效果明确,适用于严重前尿道阴茎部狭窄且局部阴茎皮肤状况良好的患者。
Objective:To evaluate the clinical effect of single-stage repair of penile urethral stricture using combined dorsal onlay oral mucosa grafting with ventral onlay penile skin flap.Methods:We retrospectively reviewed the clinical database of 22 male patients with penile urethral stricture who received single-stage repair using combined dorsal onlay oral mucosa grafting with ventral onlay penile skin flap from November 2015 to October 2018.All the cases had no complications,such as skin fistula.The causes of stricture included iatrogenic(14/22,63.6%),inflammation(2/22,9.1%) and idiopathic(6/22,27.3%).A ventral urethrotomy was made in the segment of stricture and extended proximally and distally until the normal calibre urethra was encountered.The oral mucosa graft was secured to the corpus spongiosum in dorsal onlay fashion or underlying corpora cavernosum after resection of the severe scarred urethra.Then the prepared Orandi fasciocutaneous penile skin flap was secured to edges of corpus spongiosum or oral mucosa graft.A 16 F or 14 F Foley catheter was left in situ for a minimum of 3 weeks,at which time a urethrogram was performed to look for extravasation,and the urethroscopy was performed if necessary.Success was defined as an open urethra with Qmax ≥15 mL/s and no need for further surgical intervention.Results:all the 22 patients with a mean age of 52.6(18-73) years underwent the combined tissue-transfer technique.The mean length of the penile urethral stricture was 5.3(2.5-10.0)cm and the mean preoperative Qmax was 6.7 mL/s.the mean length of oral mucosa grafts and fasciocutaneous skin flaps were 5.5(3.2-10.5) cm and 6.0(3.5-11.0) cm,respectively.The mean operation time was 225(150-420) minutes and the mean evaluated blood loss was 53(20.0-110.0) mL.The grafts included buccal mucosa(19/22,86.4%) and lingual mucosa(3/22,13.6%).The mean postoperative Q max was 21.2(15-32) mL/s.A case of skin fistula and 2 cases of recurrent stricture were found,so the technique success rate was 81.8%(18/22) at a mean follow-up of 20.5(5-51)months.The perioperative complications included 2 cases of infection and skin necrosis,which healed well after conservative treatment.Conclusion:Single-stage repair of penile urethral stricture using combined dorsal onlay oral mucosa grafting with ventral onlay penile skin flap appears to be an excellent option to repair penile urethral stricture with unsalvageable urethral plate and the penile skin is available.The present clinical series showed a successful rate of 81.8%(18/22).
Objective:To evaluate the clinical effect of single-stage repair of penile urethral stricture using combined dorsal onlay oral mucosa grafting with ventral onlay penile skin flap.Methods:We retrospectively reviewed the clinical database of 22 male patients with penile urethral stricture who received single-stage repair using combined dorsal onlay oral mucosa grafting with ventral onlay penile skin flap from November 2015 to October 2018.All the cases had no complications,such as skin fistula.The causes of stricture included iatrogenic(14/22,63.6%),inflammation(2/22,9.1%) and idiopathic(6/22,27.3%).A ventral urethrotomy was made in the segment of stricture and extended proximally and distally until the normal calibre urethra was encountered.The oral mucosa graft was secured to the corpus spongiosum in dorsal onlay fashion or underlying corpora cavernosum after resection of the severe scarred urethra.Then the prepared Orandi fasciocutaneous penile skin flap was secured to edges of corpus spongiosum or oral mucosa graft.A 16 F or 14 F Foley catheter was left in situ for a minimum of 3 weeks,at which time a urethrogram was performed to look for extravasation,and the urethroscopy was performed if necessary.Success was defined as an open urethra with Qmax ≥15 mL/s and no need for further surgical intervention.Results:all the 22 patients with a mean age of 52.6(18-73) years underwent the combined tissue-transfer technique.The mean length of the penile urethral stricture was 5.3(2.5-10.0)cm and the mean preoperative Qmax was 6.7 mL/s.the mean length of oral mucosa grafts and fasciocutaneous skin flaps were 5.5(3.2-10.5) cm and 6.0(3.5-11.0) cm,respectively.The mean operation time was 225(150-420) minutes and the mean evaluated blood loss was 53(20.0-110.0) mL.The grafts included buccal mucosa(19/22,86.4%) and lingual mucosa(3/22,13.6%).The mean postoperative Q max was 21.2(15-32) mL/s.A case of skin fistula and 2 cases of recurrent stricture were found,so the technique success rate was 81.8%(18/22) at a mean follow-up of 20.5(5-51)months.The perioperative complications included 2 cases of infection and skin necrosis,which healed well after conservative treatment.Conclusion:Single-stage repair of penile urethral stricture using combined dorsal onlay oral mucosa grafting with ventral onlay penile skin flap appears to be an excellent option to repair penile urethral stricture with unsalvageable urethral plate and the penile skin is available.The present clinical series showed a successful rate of 81.8%(18/22).
引文
[1]Mc Aninch JW,Morey AF.Penile circular fasciocutaneous skin flap in 1-stage reconstruction of complex anterior urethral strictures[J].J Urol,1998,159(4):1209-1213.
[2]Morey AF.Urethral plate salvage with dorsal graft promotes successful penile flaponlay reconstruction of severe pendulous strictures[J].J Urol,2001,166(4):1376-1378.
[3]Bayne DB,Gaither TW,Awad MA,et al.Guidelines of guidelines:a review of urethral stricture evaluation,management,and follow-up[J].Transl Androl Urol,2017,6(2):288-294.
[4]Horiguchi A.Substitution urethroplasty using oral mucosa graft for male anterior urethral stricture disease:current topics and reviews[J].Int J Urol,2017,24(7):493-503.
[5]Erickson BA,Breyer BN,Mc Aninch JW.Single-stage segmental urethral replacement using combined ventral onlay fasciocutaneous flap with dorsal onlay buccal grafting for long segment strictures[J].BJU Int,2012,109(9):1392-1396.
[6]Greenwell TJ,Venn AF,Mundy AR.Changing practice in anteriorurethroplasty[J].BJU Int,1999,83(6):631-635.
[7]Wessells H,Angermeier KW,Elliott S,et al.Male urethral stricture:American Urological Association Guideline[J].J Urol,2017,197(1):182-190.
[8]Gelman J,Sohn W.1-stage repair of obliterative distal urethral strictures with buccal graft urethral plate reconstruction and simultaneous onlay penile skin flap[J].J Urol,2011,186(3):935-938.
[9]Djordjevic ML,Majstorovic M,Stanojevic D,et al.Combined buccal mucosa graft and dorsal penile skin flap for repair of severe hypospadias[J].Urology,2008,71(5):821-825.
[10]Soliman MG,Abo Farha MA,El Abd AS,et al.Dorsal onlay urethroplasty using buccal mucosa graft versus penile skin flap for management of long anterior urethral strictures:a prospective randomized study[J].Scand J Urol,2014,48(5):466-473.
[11]满立波,王建伟.图解尿道成形术[M].北京:人民卫生出版社,2018:52-59.
[2]Morey AF.Urethral plate salvage with dorsal graft promotes successful penile flaponlay reconstruction of severe pendulous strictures[J].J Urol,2001,166(4):1376-1378.
[3]Bayne DB,Gaither TW,Awad MA,et al.Guidelines of guidelines:a review of urethral stricture evaluation,management,and follow-up[J].Transl Androl Urol,2017,6(2):288-294.
[4]Horiguchi A.Substitution urethroplasty using oral mucosa graft for male anterior urethral stricture disease:current topics and reviews[J].Int J Urol,2017,24(7):493-503.
[5]Erickson BA,Breyer BN,Mc Aninch JW.Single-stage segmental urethral replacement using combined ventral onlay fasciocutaneous flap with dorsal onlay buccal grafting for long segment strictures[J].BJU Int,2012,109(9):1392-1396.
[6]Greenwell TJ,Venn AF,Mundy AR.Changing practice in anteriorurethroplasty[J].BJU Int,1999,83(6):631-635.
[7]Wessells H,Angermeier KW,Elliott S,et al.Male urethral stricture:American Urological Association Guideline[J].J Urol,2017,197(1):182-190.
[8]Gelman J,Sohn W.1-stage repair of obliterative distal urethral strictures with buccal graft urethral plate reconstruction and simultaneous onlay penile skin flap[J].J Urol,2011,186(3):935-938.
[9]Djordjevic ML,Majstorovic M,Stanojevic D,et al.Combined buccal mucosa graft and dorsal penile skin flap for repair of severe hypospadias[J].Urology,2008,71(5):821-825.
[10]Soliman MG,Abo Farha MA,El Abd AS,et al.Dorsal onlay urethroplasty using buccal mucosa graft versus penile skin flap for management of long anterior urethral strictures:a prospective randomized study[J].Scand J Urol,2014,48(5):466-473.
[11]满立波,王建伟.图解尿道成形术[M].北京:人民卫生出版社,2018:52-59.