尿道板纵切卷管尿道成形术在尿道下裂治疗中的临床研究
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摘要
先天性尿道下裂是小儿中最常见的泌尿生殖系统先天性畸形。由于阴茎及前尿道的发育不全,尿道开口异常并伴有阴茎下曲畸形,致使患儿不能站立排尿,进而影响患儿成年后性功能及生育力。手术矫正尿道下裂畸形是本病的唯一有效的治疗措施,但术后并发症的发生率较高。临床上尿道下裂修复术后的治愈标准：①阴茎下曲完全矫正,阴茎头下曲常表现为球状阴茎头,也应矫正,恢复其正常圆锥状；②尿道口位于阴茎尖端；③阴茎外观满意,接近正常,能站立排尿,成年后能进行正常性生活。国内外虽然已有300多种手术方法的报道,但手术的选择主要依靠术者的经验和对不同类型患儿所采取的术式,缺乏一种公认的可用于治疗各种类型尿道下裂的手术方法。就手术并发症而言,临床上以尿道狭窄和尿瘘的发生率最高,达1.5%～44%不等,其发生率因不同术者、不同术式而异。极少数严重的病例虽经过多次手术,仍未能恢复到正常外生殖器的外观和功能,甚至导致尿道下裂残废。故强调对不同种类的尿道下裂采用相应的术式,避免对患儿日后身心健康的影响。尿道板是尿道下裂患者中阴茎腹侧尿道异位开口向阴茎头部伸展的尿道黏膜,本身就是原始尿道发育组织,紧密附着在阴茎海绵体上,有丰富的神经支配和良好的血供,还有未完全退化的尿道海绵体组织支撑在基底两侧,无论从组织工程学还是从临床效果上来看,尿道板已经成为尿道下裂治疗中阴茎上可以利用的修复尿道缺损的最佳材料。尿道板纵切卷管尿道成形术在修复远端尿道下裂上由于其并发症发生率低,良好的美容效果,且技术简单逐渐的获得了全世界的认可。本研究对尿道板纵切卷管尿道成形术治疗首次手术的尿道下裂及尿道板纵切卷管尿道成形术治疗失败的尿道下裂分别进行临床研究。
目的评价尿道板纵切卷管尿道成形术治疗首次手术的先天性尿道下裂临床疗效。探讨尿道板纵切卷管尿道成形术治疗失败的尿道下裂临床疗效。
方法回顾分析广州军区总医院泌尿外科2002年3月至2011年1月接受尿道板纵切卷管尿道成形术治疗的810例先天性尿道下裂患者临床资料。均为首次手术,手术年龄11个月-17岁,平均4.8岁,均采用尿道板纵切卷管成形法。留置尿道U形支架管,两端分别从会阴部尿道及尿道外口引出,在尿道板两侧切口向远端延伸至阴茎头尿道沟,近端绕尿道开口会合,呈U形。脱套包皮,充分阴茎。用人工勃起试验进行检查,如松解不满意,于阴茎体背侧弧度最大处12点位置进行白膜折叠紧缩以伸直阴茎。若尿道板宽度足够,则不必行尿道板背侧纵行切开或只切开部分尿道板,否则需纵行切开从阴茎头至尿道下裂开口的尿道板。转移阴茎背侧包皮,部分去上皮形成肉膜瓣,覆盖加固成形的尿道即肉膜瓣加固成形的尿道。
在各手术年龄组之间,各先天性尿道下裂开口位置组之间,两种尿流改道方式组之间,参照Donnahoo无尿道下裂的阴茎下曲畸形(chordee without hypospadias)的病因分类法的前3级的TIP手术患者各组之间,有无处理并发疾病组之间,对TIP手术的成功率进行比较。
回顾分析广州军区总医院泌尿外科2002年3月至2011年4月接受尿道板纵切卷管尿道成形术治疗的81例阴茎皮肤少失败的尿道下裂患者临床资料,并与在同期应用Duplay尿道成形术修复的阴茎皮肤相对充裕的失败尿道下裂36例作比较。并比较尿道下裂手术史与手术成功率的关系。
结果在首次手术的810例先天性尿道下裂患者临床资料,术中尿道下裂程度按Duckett分型：前型316例(39.0%)、中间型348例(43.0%)、后型146例(18.0%)。阴茎下曲程度按照Donnahoo分级,将尿道下裂阴茎下曲程度分为0-4级。随访6月至2年,746例手术一次成功(92.1%),150例3级阴茎下曲者采用阴茎背侧白膜折叠术纠正完成手术,新建尿道口位于阴茎头部。术后并发尿道口狭窄11例(1.4%),并发尿瘘49例(6.0%),尿道憩室4例(0.5%),均经再次手术治疗后治愈。
各手术年龄组之间,TIP手术的成功率无显著性差异(P=0.298)。按照Duckett分型,各先天性尿道下裂开口位置组之间,TIP手术的成功率无显著性差异(P=0.373)。两种尿流改道方式组之间,TIP手术的成功率无显著性差异(P=0.436)；参照Donnahoo无尿道下裂的阴茎下曲畸形(chordee without hypospadias)的病因分类法的前3级的TIP手术患者各组之间,TIP手术的成功率无显著性差异(P=0.519)；有无处理并发疾病组之间手术成功率无显著性差异(P=0.144)。。
117例失败的尿道下裂患者随访6月至2年,应用TIP术式81例,成功65例(80.2%)；尿道瘘11例,尿道狭窄5例。Duplay尿道成形术36例,成功29例(80.6%),尿道瘘5例,尿道狭窄2例。2组结果比较无显著性差异(P=0.969)。多于三次手术史患者一次手术成功率较低,为57.9%,一次手术史、二次手术史和多于三次手术史各组之间,TIP的手术成功率有显著性差异(P=0.008)。
结论尿道板纵切卷管尿道成形术可以作为先天性尿道下裂患者的首选术式,手术结果不受尿道下裂开口位置、年龄大小、引流方式、阴茎下曲畸形程度及有无处理并发疾病的影响,阴茎重度弯曲者若需采用尿道板纵切卷管尿道成形术则需行背侧海绵体折叠术。尿道板纵切卷管尿道成形术用于阴茎皮肤少的失败尿道下裂病例修复,可取得满意效果。尿道下裂手术史越多,手术成功率越低。多于三次手术史,阴茎包皮较少的尿道下裂患者可以考虑采用其它手术方式。
Background:Hypospadias is one of the most commoncongenital anomalies defined by abortive development of the urethral meatus, the penile chordee and the ventral prepuce. Some of the patients could not urinate standly with decreased reproductive activity in adult.Surgical repare is the only therapeutic measure, but the ineidence of postoperative complications is still high. The tubularized incised plate (TIP) urethroplasty or Snodgrass procedure has gained worldwide acceptance for distal hypospadias repair due to its low complication rate, good cosmetic result, and technical simplicity. The study is divided in two parts.
Part One:Tubularized incised-plate urethoplasty for hypospadias in children(810cases)
Objection:To evaluate the clinical efficacy of tubularized incised-plate urethoplasty for hypospadias repair. To evaluate the clinical efficacy of Snodgrass urethroplasty for failure hypospadias repairment with narrow urethral plate.
Methods and materials:810cases of hypospadia patients ranged from1to17years(mean,4.8years) treated with tubularized incised-plate urethoplasty in department of urology of general hospital of Guangzhou military command of PLA from March2002to January2011were reviewed and evaluated. All patients were performed in tubularized incised-plate urethoplasty.
Results:The position of the meatus was distal in316boys(39.0%), middle in348(43.0%) and posterior in146(18.0%)according to Duckett classification. The severity of chordee was graded into0-4according to Donnahoo classification.810patients were followed up from6months to2years (mean,7.5months).746(92.1%) patients were successful cured after just one repair, obtaining a neourethra with slit-like meatus at the top of the glans and satisfactory voiding function.150patients of grade3chorde repair with dorsal placation with phallocampsis.Small urethrocutaneous fistula occurred in49(6.0%) patients, mild meatal stenosis occurred in11(1.4%) patients, urethral diverticulum occurred in4(0.5%) patients and all of which were cured by the second therapy. Urethral stricture was not seen during follow-up.
117patients were followed up from6months to2years (mean,7.5months).There were65patients cured,5patients with urethral stricture and11patients with urethral fistula by using Snodgrass urethroplasty. There were29patients cured,2patients with urethral stricture and5patients with urethral fistula by using Duplay urethroplasty. The results of two groups showed no obvious differences (P=0.969). The results of groups of surgical history showed obvious differences (P=0.008).
Conclusion:Tubularized incised plate urethroplasty is the first choice of hypospadias and to severity chordee type of hypospadias by using dorsal placation with phallocampsis. The results are irrespective of surgical age. hypospadiac meatal position,the method of urinary diversion and the severity of chordee according to Donnahoo classification.
Snodgrass urethroplasty is versatile to failed hypospadias patients with insufficient local tissues. The success rate of surgery is respect to surgical history.The more surgical history leads to lower success rate of surgery.
目的评价尿道板纵切卷管尿道成形术治疗首次手术的先天性尿道下裂临床疗效。探讨尿道板纵切卷管尿道成形术治疗失败的尿道下裂临床疗效。
方法回顾分析广州军区总医院泌尿外科2002年3月至2011年1月接受尿道板纵切卷管尿道成形术治疗的810例先天性尿道下裂患者临床资料。均为首次手术,手术年龄11个月-17岁,平均4.8岁,均采用尿道板纵切卷管成形法。留置尿道U形支架管,两端分别从会阴部尿道及尿道外口引出,在尿道板两侧切口向远端延伸至阴茎头尿道沟,近端绕尿道开口会合,呈U形。脱套包皮,充分阴茎。用人工勃起试验进行检查,如松解不满意,于阴茎体背侧弧度最大处12点位置进行白膜折叠紧缩以伸直阴茎。若尿道板宽度足够,则不必行尿道板背侧纵行切开或只切开部分尿道板,否则需纵行切开从阴茎头至尿道下裂开口的尿道板。转移阴茎背侧包皮,部分去上皮形成肉膜瓣,覆盖加固成形的尿道即肉膜瓣加固成形的尿道。
在各手术年龄组之间,各先天性尿道下裂开口位置组之间,两种尿流改道方式组之间,参照Donnahoo无尿道下裂的阴茎下曲畸形(chordee without hypospadias)的病因分类法的前3级的TIP手术患者各组之间,有无处理并发疾病组之间,对TIP手术的成功率进行比较。
回顾分析广州军区总医院泌尿外科2002年3月至2011年4月接受尿道板纵切卷管尿道成形术治疗的81例阴茎皮肤少失败的尿道下裂患者临床资料,并与在同期应用Duplay尿道成形术修复的阴茎皮肤相对充裕的失败尿道下裂36例作比较。并比较尿道下裂手术史与手术成功率的关系。
结果在首次手术的810例先天性尿道下裂患者临床资料,术中尿道下裂程度按Duckett分型：前型316例(39.0%)、中间型348例(43.0%)、后型146例(18.0%)。阴茎下曲程度按照Donnahoo分级,将尿道下裂阴茎下曲程度分为0-4级。随访6月至2年,746例手术一次成功(92.1%),150例3级阴茎下曲者采用阴茎背侧白膜折叠术纠正完成手术,新建尿道口位于阴茎头部。术后并发尿道口狭窄11例(1.4%),并发尿瘘49例(6.0%),尿道憩室4例(0.5%),均经再次手术治疗后治愈。
各手术年龄组之间,TIP手术的成功率无显著性差异(P=0.298)。按照Duckett分型,各先天性尿道下裂开口位置组之间,TIP手术的成功率无显著性差异(P=0.373)。两种尿流改道方式组之间,TIP手术的成功率无显著性差异(P=0.436)；参照Donnahoo无尿道下裂的阴茎下曲畸形(chordee without hypospadias)的病因分类法的前3级的TIP手术患者各组之间,TIP手术的成功率无显著性差异(P=0.519)；有无处理并发疾病组之间手术成功率无显著性差异(P=0.144)。。
117例失败的尿道下裂患者随访6月至2年,应用TIP术式81例,成功65例(80.2%)；尿道瘘11例,尿道狭窄5例。Duplay尿道成形术36例,成功29例(80.6%),尿道瘘5例,尿道狭窄2例。2组结果比较无显著性差异(P=0.969)。多于三次手术史患者一次手术成功率较低,为57.9%,一次手术史、二次手术史和多于三次手术史各组之间,TIP的手术成功率有显著性差异(P=0.008)。
结论尿道板纵切卷管尿道成形术可以作为先天性尿道下裂患者的首选术式,手术结果不受尿道下裂开口位置、年龄大小、引流方式、阴茎下曲畸形程度及有无处理并发疾病的影响,阴茎重度弯曲者若需采用尿道板纵切卷管尿道成形术则需行背侧海绵体折叠术。尿道板纵切卷管尿道成形术用于阴茎皮肤少的失败尿道下裂病例修复,可取得满意效果。尿道下裂手术史越多,手术成功率越低。多于三次手术史,阴茎包皮较少的尿道下裂患者可以考虑采用其它手术方式。
Background:Hypospadias is one of the most commoncongenital anomalies defined by abortive development of the urethral meatus, the penile chordee and the ventral prepuce. Some of the patients could not urinate standly with decreased reproductive activity in adult.Surgical repare is the only therapeutic measure, but the ineidence of postoperative complications is still high. The tubularized incised plate (TIP) urethroplasty or Snodgrass procedure has gained worldwide acceptance for distal hypospadias repair due to its low complication rate, good cosmetic result, and technical simplicity. The study is divided in two parts.
Part One:Tubularized incised-plate urethoplasty for hypospadias in children(810cases)
Objection:To evaluate the clinical efficacy of tubularized incised-plate urethoplasty for hypospadias repair. To evaluate the clinical efficacy of Snodgrass urethroplasty for failure hypospadias repairment with narrow urethral plate.
Methods and materials:810cases of hypospadia patients ranged from1to17years(mean,4.8years) treated with tubularized incised-plate urethoplasty in department of urology of general hospital of Guangzhou military command of PLA from March2002to January2011were reviewed and evaluated. All patients were performed in tubularized incised-plate urethoplasty.
Results:The position of the meatus was distal in316boys(39.0%), middle in348(43.0%) and posterior in146(18.0%)according to Duckett classification. The severity of chordee was graded into0-4according to Donnahoo classification.810patients were followed up from6months to2years (mean,7.5months).746(92.1%) patients were successful cured after just one repair, obtaining a neourethra with slit-like meatus at the top of the glans and satisfactory voiding function.150patients of grade3chorde repair with dorsal placation with phallocampsis.Small urethrocutaneous fistula occurred in49(6.0%) patients, mild meatal stenosis occurred in11(1.4%) patients, urethral diverticulum occurred in4(0.5%) patients and all of which were cured by the second therapy. Urethral stricture was not seen during follow-up.
117patients were followed up from6months to2years (mean,7.5months).There were65patients cured,5patients with urethral stricture and11patients with urethral fistula by using Snodgrass urethroplasty. There were29patients cured,2patients with urethral stricture and5patients with urethral fistula by using Duplay urethroplasty. The results of two groups showed no obvious differences (P=0.969). The results of groups of surgical history showed obvious differences (P=0.008).
Conclusion:Tubularized incised plate urethroplasty is the first choice of hypospadias and to severity chordee type of hypospadias by using dorsal placation with phallocampsis. The results are irrespective of surgical age. hypospadiac meatal position,the method of urinary diversion and the severity of chordee according to Donnahoo classification.
Snodgrass urethroplasty is versatile to failed hypospadias patients with insufficient local tissues. The success rate of surgery is respect to surgical history.The more surgical history leads to lower success rate of surgery.
引文
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