预置"尿道板"的分期手术治疗严重尿道下裂

目的 评价分期手术治疗严重尿道下裂的效果.方法 2001年12月至2009年8月治疗27例严重尿道下裂患儿,年龄8个月至17岁,平均4.3岁.近端型伴重度阴茎下弯23例,既往手术失败组织挛缩4例.Ⅰ期手术:完全脱套包皮,切除阴茎腹侧纤维束带或瘢痕组织,完全伸直阴茎,游离带蒂岛状包皮内板转移至腹侧填补缺损,预置"尿道板",包皮内板缺乏侧取下唇口腔黏膜皮瓣.术后6个月Ⅱ期手术:手术方式采用尿道板纵切卷管尿道成形术.4例皮瓣与尿道板连接处出现瘢痕愈合,予瘢痕切除,口腔黏膜镶嵌后卷管成形尿道.结果 27例患儿中,无尿道狭窄、皮瓣坏死等发生,4例术后尿瘘,6个月后再修补.结论 严重尿道下裂病例采用预置"尿道板"的分期手术,单次的手术操作简化,充分结合了传统尿道板卷管术式的优点,成功率高,整形效果好.     

预置"尿道板"的分期手术治疗严重尿道下裂

目的 评价分期手术治疗严重尿道下裂的效果.方法 2001年12月至2009年8月治疗27例严重尿道下裂患儿,年龄8个月至17岁,平均4.3岁.近端型伴重度阴茎下弯23例,既往手术失败组织挛缩4例.Ⅰ期手术:完全脱套包皮,切除阴茎腹侧纤维束带或瘢痕组织,完全伸直阴茎,游离带蒂岛状包皮内板转移至腹侧填补缺损,预置"尿道板",包皮内板缺乏侧取下唇口腔黏膜皮瓣.术后6个月Ⅱ期手术:手术方式采用尿道板纵切卷管尿道成形术.4例皮瓣与尿道板连接处出现瘢痕愈合,予瘢痕切除,口腔黏膜镶嵌后卷管成形尿道.结果 27例患儿中,无尿道狭窄、皮瓣坏死等发生,4例术后尿瘘,6个月后再修补.结论 严重尿道下裂病例采用预置"尿道板"的分期手术,单次的手术操作简化,充分结合了传统尿道板卷管术式的优点,成功率高,整形效果好.     

耦合法尿道成形术在中重度阴茎下弯的阴茎体型尿道下裂的应用

目的探讨采用口腔黏膜片移植与包皮内板转移皮瓣耦合组建尿道修复尿道下裂的手术方式。方法回顾性分析2013年3月至2014年6月本院15例中重度阴茎下弯的阴茎体型道下裂患儿,采用口腔黏膜片移植与包皮内板转移皮瓣相结合的耦合法组建尿道修复尿道下裂的病历资料。结果15例中重度阴茎下弯的阴茎体型尿道下裂患儿中,1例出现尿瘘经修补治愈;1例出现尿道狭窄,经尿道扩张后治愈,其余均一期治愈。术后随访1年,15例阴茎下弯矫正满意,尿道开口正位,阴茎龟头外形较好,再造尿道通畅。结论应用口腔黏膜片移植与包皮内板转移皮瓣相结合的耦合法组建修复尿道,是一种修复尿道下裂的良好方法,术后并发症少,值得临床推广。     

下唇黏膜代尿道在尿道下裂治疗中的应用

目的 分析评估下唇黏膜代尿道在复杂性尿道下裂手术中的应用价值.方法 2006年3月至2009年10月共对24例复杂性尿道下裂患儿施行了下唇黏膜代尿道手术.年龄2岁3个月至14岁,平均7.2岁.其中以往手术失败14例,表现为阴茎周围残留大量不规则瘢痕,或膀胱黏膜代尿道后严重尿道狭窄和憩室.或严重阴茎海绵体弯曲残留,或尿道大段缺损伴膀胱造瘘术后等,尿道周围无其他组织如尿道板、皮肤等可用替代尿道.手术方法为先行阴茎整形,包括包皮和阴茎头,完全矫正海绵体弯曲,6个月后行下唇黏膜代尿道手术.会阴型尿道下裂10例,方法为先完全矫正阴茎弯曲和阴茎阴囊转位,同时利用原始尿道板将尿道外口从会阴延长至阴茎根部,6个月后行下唇黏膜代尿道.结果 所有病例均获满意效果,包括阴茎外观,即阴茎勃起时无明显弯曲、尿道开口位于阴茎头顶端、无包皮不规则瘢痕堆积、无排尿困难等.术后9例出现尿瘘,其中2例术后自愈,7例经一次修补后治愈.出现尿道狭窄6例,均经尿道扩张后痊愈.下唇取黏膜处均无术后出血.结论 下唇黏膜代尿道可作为尿道下裂治疗中最后选择的方法之一,具有黏膜切取方便,易存活,新尿道组织黏膜接近正常组织的优点,但并发症发生率仍较高.     

改良尿道板纵切卷管尿道成型术治疗儿童尿道下裂62例

目的总结改良的分层覆盖缝合尿道板纵切卷管尿道成型术（TIP,Tubularized Incised Plate）在儿童尿道下裂手术中的应用经验。方法2010年1月至2012年1月作者应用TIP法治疗尿道下裂患儿62例,年龄6个月至7岁,其中5例为再次手术患儿。尿道板纵切卷管尿道成型后改良方法：采用阴茎背侧皮肤下带蒂血管筋膜转移至腹侧人工尿道上覆盖后,再用全层包皮两翼向腹侧包绕的分层缝合覆盖的方法。结果62例患儿中,57例术后阴茎伸直,外形美观,排尿正常。术后出现尿瘘2例,经二次手术修补尿瘘及尿道成型失败后再手术3例,一次手术成功率为91．9％。结论1rIP分层覆盖缝合后人工尿管血运改善,成功率高。手术时应使尿道板纵切卷管无张力缝合成型,分层解剖时避免损伤各层供应血管,是改良TIP的关键。     

阴囊中缝带蒂皮瓣转移覆盖在尿道下裂多次手术皮肤缺损患儿中的应用

目的分析重度尿道下裂多次手术皮肤缺损患儿采用口腔黏膜镶嵌式尿道成形阴囊中缝带蒂皮瓣转移覆盖术的治疗效果。方法收集2013年10月至2016年10月间入住本院的16例尿道下裂手术治疗失败需再次手术病例,年龄4~13岁,平均年龄7.5岁。尿道重塑均采用口腔黏膜镶嵌尿道成形术,再游离阴囊中缝带蒂皮瓣将之转移至阴茎腹侧创区皮肤缺损处,均顺利完成手术。结果16例患儿术后均通过电话预约门诊复查完成随访,随访时间12~24个月,平均随访时间为15个月。患儿阴囊中缝转移皮瓣均成活,排尿顺畅,尿道外口位置良好,无尿道憩室和尿道瘘发生,阴茎阴囊外观患儿家长满意。结论多次进行手术修补失败的尿道下裂患儿采用口腔黏膜镶嵌尿道成形术重塑尿道后联合阴囊中缝带蒂皮瓣转移覆盖术治疗,术后患儿阴茎阴囊外观满意,无尿道憩室尿道瘘发生,疗效满意,治愈率高,值得临床推广应用。     

组织工程补片在重度尿道下裂分期手术中的应用

目的对于重度尿道下裂,阴茎发育不良,并发严重阴茎下弯的患儿,阴茎矫直后多数会伴有阴茎腹侧白膜的缺损。本研究采用异体组织工程皮肤脱细胞基质(Decellularized Matrix)材料来修补阴茎腹侧白膜横断后的缺损,探讨其改善阴茎矫直的效果,为二期手术提供良好的基础。方法本研究收集2011年6月至2016年9月由本院收治的82例需要分期手术的重度尿道下裂患儿作为研究对象。常规脱鞘后,横断尿道板,松解腹侧尿道瘢痕组织,腹侧白膜切开后根据大小裁剪合适的异体组织工程皮肤脱细胞基质修复白膜缺损,根据情况取背侧包皮内板横裁岛状皮瓣预留尿道板,二期行Snodgrass手术。结果 82例均为重度尿道下裂,经染色体检查和/或SRY基因检查证实为男性。阴茎发育不良,伴有严重的阴茎下弯,一期手术均取得成功,无皮瓣坏死,无严重并发症。二期手术人工勃起实验均证实阴茎伸直状态,手术中未见有明显皮肤补片残留,术后尿道口狭窄6例(7. 3%),尿瘘9例(11%),尿道憩室2例(2. 4%),术后尿道开口位于龟头,排尿通畅,阴茎外观良好。结论采用组织工程皮肤补片可以简化手术操作,容易掌握,手术并发症少,而且修复后阴茎外观饱满,可以获得类似包皮环切术后样外观,取得满意的手术效果,是一种可以选择的方法。     

阴囊中缝带蒂皮瓣治疗尿道下裂的临床应用体会

目的 探讨带蒂阴囊中缝带蒂皮瓣转移覆盖技术在治疗尿道下裂病例多次手术后皮肤缺损中的适应证与疗效.方法 2014年2月至2015年1月,收集我院12例患儿,年龄5～15岁,平均8.4岁.均为外院多次尿道下裂术后失败患儿.为再次治疗入我院.所有患儿均接受口腔黏膜镶嵌尿道成形术一次完成手术.完成尿道重塑后,在阴囊皮肤血供解剖学的基础上,对于重度尿道下裂患儿经多次术后皮瓣遭严重破坏而不足的患儿,采用阴囊中缝皮瓣游离,转移覆盖于阴茎腹侧创面皮肤缺损处.结果 术后随访6～12个月,平均8.3个月,12例患儿全部获得随访,所有患儿皮瓣完全成活,无尿道瘘及尿道憩室,术后2周出现尿道狭窄1例.接受会阴尿道镜检查,确定为口腔黏膜与原尿道吻合口狭窄,扩张后治愈.长期随访患儿阴茎下弯矫正满意,尿道外口位于阴茎头正位,排尿通畅,无尿道瘘、尿道狭窄、尿道憩室等.阴茎及阴囊外观满意.结论 对于接受多次尿道下裂修补术后需要重新接受手术的患儿,由于多次手术对阴茎皮瓣破坏严重,再次行尿道下裂修补术时,我们选择游离带蒂阴囊中缝皮瓣覆盖新尿道,较传统上阴茎阴囊皮肤覆盖新尿道的张力较低,覆盖范围广并避免了皮肤的臃肿感.该手术方法简单,操作难度不高,成功率高,术后并发症少,外形美观,值得临床推广应用.     

分期手术在尿道下裂修复中的应用

目的评价尿道下裂分期手术的疗效,并与一期手术比较,分析其优缺点。方法自2006年6月至2015年6月我们对320例尿道下裂患者行尿道下裂分期手术,均一期先行阴茎下曲矫正,包皮内板腹侧转移术;待6个月后行二期带蒂包皮卷管尿道成形术。结果 320例中,二期手术成功290例(290/320,90.6%),出现尿瘘28例(28/320,8.75%),尿道狭窄2例(2/320,0.65%)。结论①分期手术成功率与一期手术成功率相近,但尿道狭窄发生率明显减少。②分期手术外观更接近正常生理状况。③分期手术适应症广泛,特别适用于长段尿道缺损、阴茎龟头裂开,多次手术失败、阴茎细小病例。④分期手术可简化操作,手术成功率保障性高,值得推广应用。     

218例Duckett手术成功率的多因素回归分析

横裁包皮岛状皮瓣卷管尿道成形术(Duckett术)是治疗尿道下裂的经典术式.近年来随着尿道板纵切卷管尿道成形术(TIP术)和加盖岛状皮瓣尿道成形术（Onlay术)的开展,以及分期手术的同归,操作复杂难以掌握的Duckett手术似有被代替的倾向[1].但是对于合并明显阴茎下曲的病例,Duckett手术仍然有不可或缺的优势,如Ⅰ期成形和外形美观[2].2005年9月至2011年7月本院采用Duckett手术治疗218例尿道下裂患儿,成功156例,成功率71.6％.现就本组手术成功率的影响因素进行单因素和Logistic多因素回归分析,报告如下.     

Urethral reconstruction using an autologous bladder mucosal graft

Since 1988 twelve children underwent urethral reconstruction by using an autologous bladder mucosal graft. In 10 of these previous surgery for hypospadias or other penile anomalies had failed. Bladder mucosal graft was used in 2 cases for primary urethral reconstruction. Our results in using this method, mostly in hypospadias cripples, are satisfying, so that we are encouraged to use the autologous bladder mucosal graft for primary urethral reconstruction in selected cases with severe forms of hypospadias as well.     

Use of an inner preputial free graft to extend the indications of Snodgrass hypospadias repair (Snodgraft)

Tubularized incised plate (tip) urethroplasty or Snodgrass repair has become the most commonly used procedure for distal hypospadias repair. However, where the urethral plate is narrow or shallow, the good results may be compromised. We present our experience of using a small inner preputial graft to deepen and widen the urethral plate (Snodgraft). This procedure has certainly reduced the number of two-stage hypospadias repairs in patients who lack a urethral groove or have a small glans. The cosmetic and functional results are excellent.     

The Single Stage Dorsal Inlay Skin Graft for Hypospadias Reoperations: Long-Term Follow-Up

PurposeDespite high success rates for primary hypospadias repair, some patients still require multiple sessions for ultimate functional reconstruction. We report our long-term experience with single stage dorsal inlay urethroplasty using skin grafts for complex hypospadias reoperations.Material and Methods35 patients (mean 13.8 years) with failed hypospadias surgery (mean 4.2 times) were included. Indications comprised fistulas, strictures, diverticula, and repair breakdown. The urethral plate had been removed or was scarred in all patients. After excision of fibrotic tissue a free penile or groin skin graft was sutured and quilted to the corpora cavernosa. The neourethra was tubularized followed by glanuloplasty in a single stage. Clinical outcome was considered a failure when any postoperative instrumentation was needed.ResultsPenile skin was used in 31 and inguinal skin in 4 cases.The average graft length was 4.87 cm. Initial graft healing was successful in all cases. We did not note complications from the graft donor sites. After a mean follow up of 55.73 +/- 18.26 months 5 patients underwent redo surgery leaving a complication rate of 14.3 %. Urethral stricture of the proximal anastomosis was the most frequent finding. Single internal urethrotomy was sufficient for 2 boys whereas 2 finally required another urethroplasty using the same technique.ConclusionsThis single stage approach using dorsal inlay skin grafts is a reliable method to create a substitute urethral plate for tubularization. Complication rates are equivalent to those of staged strategies with the advantage of only one hospital stay. Residual penile skin should be used as a graft donor site to optimize the outcome if available. Given the excellent long term follow-up, this approach represents a safe option for hypospadias re-operations even if the urethral plate or midline penile skin is grossly scarred.     

Is tubularization of the mobilized urethral plate a better alternative to tubularization of an incised urethral plate for hypospadias repair?

Introduction  Trial of a new procedure of hypospadias repair based on the incorporation of the entire available innate urethral tissue for the formation of neo-urethra in patients with hypospadias. Materials and methods  Fifteen consecutive children, nine with distal hypospadias and six with proximal hypospadias (all with severe chordee), whose parents consented to application of a new procedure of hypospadias repair, were the study subjects. This procedure is inspired by Cantwell Ransley procedure for epispadias repair and Snodgras procedure for hypospadias repair. The entire urethral plate was mobilized (i.e., lifted off the corpora) distal to the urethral meatus and was tubularized in two layers; inner urethral skin and outer spongiosal tissue, in Duplay fashion. The repair was reinforced with dartos vascularized flap. The skin incisions on the urethral strip are guided by the disposition of the spongiosal tissue underlying the urethral plate (rather than the conventional U-shaped incision on either side of hypospadiac urethral meatus). In the patients with proximal hypospadias with severe chordee urethral advancement was combined to achieve orthoplasty and a single stage hypospadias repair. The catheter was removed on tenth postoperative day. Results  Even in patients with proximal hypospadias with severe chordee, good single staged repair was achieved without resorting to dorsal plication that would have been necessary had any other methods based on the preservation of urethral plate was performed in these subjects. Therefore, the procedure was found to have an extended applicability to even those patients where tubularized incised urethral plate urethroplsty is not advised. All patients had good results (in 1 year follow-up), except in three early subjects of the series; two of whom developed minor urethrocutaneous fistulae (probably due to frank urinary leak secondary to repeated catheter blockade) and one developed partial glanular wound dehiscence. Conclusions  Though the authors have an initial limited experience with this procedure, the procedure is likely to have a promising future due to its versatility and utilization of the entire urethral tissue.     

Byars two-stage procedure for hypospadias after urethral plate transection

ObjectiveTo report on the outcomes of primary hypospadias repaired with the Byars two-stage procedure.Materials and methodsPrimary hypospadias repairs with the Byars two-stage procedure, between 2009 and 2012, were retrospectively reviewed. Medical charts were reviewed and analyzed. Follow up was at two weeks, three months, six months and one year after surgery. Complications, which included fistula, glans dehiscence, meatal stenosis, urethral stricture, diverticulum, recurrent penile curvature and others, were documented and analyzed.ResultsOne hundred and twenty-eight cases were included in the present study. The median follow up was 30 months (range 13–44 months). All flaps took successfully after the first stage. Overall complication rates were 11.8%. Complications included: seven cases of fistula; five glans dehiscence; two urethral strictures, which developed after fistula repair; and one concealed penis. No recurrent penile curvature was recorded.ConclusionsThe Byars two-stage procedure is an option for primary hypospadias when the urethral plate is transected. It had an 11.8% complication rate in this present study.     

镶嵌式唇黏膜尿道成形术在复杂尿道下裂治疗中的应用

目的探讨复杂尿道下裂的治疗以及术后尿道狭窄的预防。方法从2005年5月至2005年10月，我们在Snodgrass尿道成形术基础上，通过将游离的自体唇黏膜瓣镶嵌于劈开的“尿道板”再卷管形成新尿道的方法对23例经过至少1次手术的复杂尿道下裂病例进行再次手术治疗并评价其效果。结果所有病例术后均无明显的尿道狭窄，尿瘘发生率17．4％（4／23）。无尿道憩室形成和尿道口黏膜增生外翻。结论镶嵌式唇黏膜尿道成形术兼有Snodgrass尿道成形术和游离移植物代尿道成形术的优点，是治疗尿道下裂合并尿道狭窄的有效方法；对于尿道板发育不良或经阴茎伸直术后的重度尿道下裂病例，镶嵌唇黏膜具有预防尿道狭窄的作用。     

445例先天性尿道下裂的治疗

目的 探讨不同术式对445例不同类型先天性尿道下裂患儿的手术治疗效果。方法 回顾性分析我院1988年—2003年445例先天性尿道下裂病例资料，其中采用阴茎阴囊纵隔带蒂皮瓣尿道成型术311例，包皮内板带蒂皮瓣尿道成型术52例，包皮及阴茎阴囊联合皮瓣尿道成型术61例，膀胱粘膜代尿道术21例。每例均同时行耻骨上膀胱造瘘术。结果 治愈率90．6％，并发症为9．4％。其中尿道狭窄11例，尿瘘31例。尿道狭窄中膀胱粘膜法1例，包皮内板法2例，阴茎阴囊纵隔法5例，联合皮瓣法3例；尿瘘中膀胱粘膜法1例，包皮内板法3例，阴茎阴囊纵隔法24例，联合皮瓣法3例。结论 根据尿道下裂类型选择不同的术式 尿流改道，并严格遵守整形外科的原则是尿道下裂手术成功的关键。