口腔内黏膜尿道成形治疗前尿道狭窄10年经验总结

目的 探讨口腔内黏膜尿道成形治疗尿道狭窄的长期效果. 方法 2001年1月至2010年12月,应用口腔内黏膜(颊黏膜和舌黏膜)尿道成形治疗前尿道狭窄255例.尿道狭窄段长度3 ～18 cm,平均6 cm.尿道成形采用保留原尿道板的扩大尿道成形术或埋藏黏膜条背侧替代尿道成形术.对49例尿道狭窄段≥8 cm者采取双侧颊黏膜拼接、颊粘膜与舌黏膜拼接或双侧连续长条舌黏膜尿道成形. 结果 术后随访8 ～120个月,平均37个月.230例患者排尿通畅,尿线粗,最大尿流率为16～51 ml/s,平均26 ml/s.尿道造影显示重建段尿道管腔通畅.总成功率90.2％.25例患者于术后1年内发生并发症,其中尿道再次狭窄17例,尿道皮肤瘘8例.17例尿道再狭窄患者中15例再次行口腔内黏膜尿道成形,2例吻合口狭窄行尿道内切开,术后排尿通畅;8例尿道皮肤瘘均接受尿瘘修补术后治愈. 结论 口腔颊黏膜和舌黏膜均是良好的尿道替代物,舌黏膜取材较颊黏膜更为便利;口腔内多种黏膜的组合移植重建尿道是治疗长段前尿道狭窄( ≥8 cm)的有效方法.     

游离黏膜组织重建尿道治疗复杂性尿道狭窄的临床研究

目的 探讨利用游离黏膜一期尿道成形治疗复杂性尿道狭窄或闭锁的疗效。方法 2000年8月至2004年7月采用2种游离黏膜一期尿道成形术治疗73例复杂性尿道狭窄。术前42例已行耻骨上膀胱造瘘，余31例最大尿流率1．2～6．5ml／s。用游离结肠黏膜(n=22)重建尿道长10～18cm，平均13cm；用口腔黏膜(n=51)重建尿道长3～11cm，平均5cm。术后随访分别行逆行尿道造影及尿流率，部分患者行尿道镜检查。结果随访2～48个月，平均19个月。术后排尿通畅67例(91．8％)。发生再次狭窄4例，其中结肠黏膜重建者1例，口腔黏膜重建者3例；排尿欠畅2例，定期行尿道扩张；尿道皮肤瘘2例；结肠腹壁瘘1例。1例结肠黏膜重建尿道者术后47个月移植物活检示结肠黏膜的组织形态学基本无变化。结论口腔与结肠黏膜均可作为较理想的尿道替代物，口腔黏膜较适合狭窄段不长的尿道修复，结肠黏膜较适合复杂性超长段尿道狭窄或缺损的治疗。     

DORSAL ONLAY GRAFT URETHROPLASTY USING PENILE SKIN OR BUCCAL MUCOSA IN ADULT BULBOURETHRAL STRICTURES

Purpose

Preputial skin graft is used routinely for urethral reconstruction in patients with stricture disease. Alternative donor sites include extrapenile skin, bladder mucosa and buccal mucosa. Recently buccal mucosa graft has been suggested when local epithelial tissue is not available. We describe our experience with 37 patients undergoing 1-stage correction of bulbar urethral stricture using a penile skin (31) or buccal mucosa (6) graft.

Materials and Methods

In 37 patients with bulbar urethral strictures a nontubularized dorsal onlay graft was used for urethral reconstruction. A preputial skin graft was used in 31 patients and a buccal mucosa graft in 6 with a paucity of local skin. Buccal mucosa graft length ranged from 2.5 to 5 cm. (average 4) and preputial skin graft was 2.5 to 12 cm. long (average 4.7). A dorsal approach to the urethral lumen was used in all patients who underwent onlay graft urethroplasty.

Results

Mean followup was 21.5 months for all 37 patients, 23 months for 31 treated with preputial skin graft and 13.5 months for 6 treated with buccal mucosa graft. The clinical outcomes were considered a failure anytime postoperative instrumentation was needed, including dilatation. In the series 34 cases (92%) were classified as a success and 3 (8%) as failure.

Conclusions

Onlay graft urethroplasty provided excellent results in 92% of adults with bulbourethral stricture. The dorsal approach to the urethra allowed the use of foreskin or buccal mucosa graft for reconstruction of the adequate urethral lumen.     

One-stage circumferential buccal mucosa graft urethroplasty for bulbous stricture repair

A one-stage onlay urethroplasty, using a buccal mucosa graft, is presented for patients with bulbous strictures in whom the urethral mucosa is seriously involved in the disease. Of 40 patients who underwent a dorsal buccal mucosa graft urethroplasty for bulbous urethral strictures, 5 required complete removal of the urethral mucosa and its replacement by a buccal mucosa graft. All these patients had undergone previous urethrotomy with a false passage inside the bulbous urethra and had a suprapubic tube in place. The goal of removal and replacement of the urethral mucosa in each case was to create a new, wide urethral mucosal bed to promote successful one-stage reconstruction. All patients voided spontaneously without problems after removal of the catheter. After 4 months, the mean peak flow was 21 mL/s. After 6 months, urethroscopy did not show any stricture recurrence. None of the patients required instrumentation or dilation. In patients with bulbous urethral strictures and false passage into the mucosa and spongiosum tissues, the complete removal and replacement of the urethral mucosa using a circumferential buccal mucosa graft promotes successful one-stage urethral reconstruction.     

口腔粘膜游离移植再造尿道

目的：探讨采用口腔粘膜游离移植，对局部缺乏组织的尿道下裂行尿道再造的方法。方法：1998－2001年对25例患者应用口腔粘膜游离移植再造阴茎段尿道，半年后吻合瘘口。结果：1例一期术后并发感染，愈后无尿道狭窄，所有病例二期吻合瘘口后，再造尿道通畅。结论：口腔粘膜丰富的网状毛细血管网、韧厚的上皮层和相对较薄的皮下板层结构是移植成功的关键。以口腔粘膜游离移植行尿道再造是一种可行的方法。     

Bulbar urethral stricture repair with buccal mucosa graft urethroplasty

OBJECTIVES: Evaluation of the use of buccal mucosa graft as single-stage urethral reconstruction in an adult population with a stenosis of the bulbar urethra. METHODS: In our Department between April 1996 and February 1999, 20 patients with bulbar urethra stenosis underwent single-stage urethroplasty using a buccal mucosa graft. Mean age of patients was 52 years (range 14-70). The etiology of urethral stricture was inflammation (4 cases), iatrogenic (5 cases) and idiopathic (11 cases). A ventral onlay patch (mean length 3.6 cm, range 2.5-5) was employed in all cases. RESULTS: During the follow-up (median 13 months, range 6-28) the overall success rate was 80%. The success rate was 75% for inflammatory strictures, 80% for iatrogenic strictures and 81% for strictures of unknown etiology. CONCLUSIONS: Although longer follow-up is needed, free graft urethroplasty with buccal mucosa graft represents a simple surgical option which has produced encouraging results. This is probably due to the quality of the tissue employed which at present seems to represent the first-choice solution in selected cases.     

Buccal mucosa urethroplasty for the treatment of bulbar urethral strictures

PURPOSE: We report the results of urethroplasty with a free graft of buccal mucosa as a dorsal onlay for the treatment of bulbar urethral strictures. MATERIALS AND METHODS: Since June 1994, 30 patients with bulbar urethral strictures have been treated with buccal mucosa urethroplasty. Urethroplasty was performed with a free graft of buccal mucosa using a ventral onlay in the first 7 patients and a dorsal onlay in 23. Dorsal urethrotomy was performed with a Sachse urethrotome after the bulbar urethra was separated from the corpora. The buccal mucosa onlay was sutured to the urethra and corpora cavernosa to ensure a patent urethra. RESULTS: At 20-month followup (range 3 to 50) the success rate was 96% (29 of 30 patients). Urethral stricture recurred in only 1 of 7 patients in the ventral onlay and none of 23 in the dorsal onlay group. CONCLUSIONS: Preliminary results of urethroplasty for bulbar urethral strictures with a dorsal onlay graft of buccal mucosa are excellent. Longer followup is needed to evaluate definitive results.     

结肠粘膜重建尿道的动物实验与临床应用

目的　探讨结肠粘膜代尿道治疗复杂性前尿道长段狭窄或闭锁的可行性。　方法　 6条雌性杂种成年狗在全麻下切开尿道 ,剥离全段尿道粘膜 ,取相等长度的结肠粘膜替代尿道粘膜 ,12周后将狗处死 ,取尿道组织作病理检查。采用结肠粘膜替代尿道一期尿道成形术治疗 1例复杂性前尿道长段狭窄患者 ,术后 3个月分别行逆行尿道造影 ,尿道镜和尿流率检查。　结果　 6条狗移植于尿道的结肠粘膜全部成活 ,部分腺上皮转变为移行上皮细胞。采用结肠粘膜替代尿道的患者术后排尿通畅 ,移植段尿道无狭窄 ,最大尿流率 30ml/s。　结论　结肠粘膜代尿道是治疗复杂性前尿道长段狭窄或闭锁的一种有效方法 ,可用于不适合应用包皮或膀胱粘膜及颊粘膜时的尿道重建     

Combined dorsal plus ventral double buccal mucosa graft in bulbar urethral reconstruction

OBJECTIVES: We describe a technique for bulbar urethral reconstruction using a combined dorsal plus ventral double buccal mucosa graft (BMG). METHODS: From March 2002 to June 2006, 48 men, mean age 35 yr, with bulbar strictures underwent patch urethroplasty using a dorsal plus a ventral double BMG. Average stricture length was 3.65 cm (range: 2-10 cm). The stenotic urethral segment was opened along its ventral surface; the exposed dorsal urethra was incised in the midline to create an elliptical area over the tunica albuginea where the dorsal inlay BMG was placed and quilted to the corpora to augment dorsally the urethral plate. Subsequently, the ventral onlay BMG was sutured to the urethral lateral margins to complete the augmented urethroplasty. Finally, the spongiosum was closed over the graft. Successful reconstruction was defined as normal voiding without the need for any postoperative procedure including dilation. RESULTS: Mean follow-up was 22 mo (range: 13-59 mo). At the catheter removal 3 wk after surgery, in three patients the voiding cystourethrography showed a fistula, which recovered after a prolonged catheterization. Of 48 cases, 43 (89.6%) were successful and 5 (10.4%) failures with recurrence of the stricture; 4 were treated with internal urethrotomy and 1 with a temporary perineal urethrostomy. CONCLUSIONS: Preliminary results with a combined double BMG urethroplasty for severe bulbar stricture are encouraging. The double dorsal and ventral graft may provide a simple and reliable solution to achieve an adequate urethral lumen in selected patients.     

镶嵌式唇黏膜瓣尿道成形术治疗前尿道狭窄

目的：探讨唇黏膜在前尿道狭窄中的应用及效果。方法：对8例前尿道狭窄患者采用镶嵌式唇黏膜尿道成形术治疗。手术以Snodgrass尿道成形术为基础,将狭窄段的尿道完全敞开,取游离的自体唇黏膜瓣镶嵌于背侧劈开的“尿道板”后卷管形成的新尿道。结果：全部病例术后均无明显的尿道狭窄,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尿道成形术和唇黏膜尿道成形术的优点,是治疗前尿道狭窄的好方法。     

镶嵌式口腔黏膜尿道成形术治疗尿道下裂的临床分析

目的 探讨镶嵌式口腔黏膜尿道成形术治疗尿道下裂的效果. 方法 2005年1月至2010年12月343例尿道下裂患者行镶嵌式口腔黏膜尿道成形术.年龄6个月～61岁,平均7岁.初次手术147例,其中远端型尿道下裂124例,近端型23例;再手术196例,其中远端型尿道下裂137例,近端型59例.手术方法:将取下唇口腔黏膜补片填补于尿道板中间切开间隙,再将尿道板卷管成形尿道;切取口腔黏膜宽0.5 ～2.5 cm,长1.0～8.5 cm.对于再次手术病例,术中需切除瘢痕组织.结果 术后随访6～36个月,平均16个月.147例初次手术病例中,手术成功132例(89.8％),发生尿瘘14例(9.5％),尿道狭窄2例(1.4％),其中1例近端型病例为尿瘘合并尿道狭窄.196例再手术病例中手术成功157例(80.1％),发生尿瘘32例(16.3％)、尿道狭窄13例(6.6％),其中1例远端型和5例近端型病例为尿瘘合并尿道狭窄. 结论 尿道板切开后镶嵌口腔黏膜治疗尿道下裂具有成功率高,整形效果好,对口腔外观、功能无影响等优点.     

Dorsal graft urethroplasty for female urethral stricture

PURPOSE: Urethral strictures in females are uncommon, and treatment options and outcome are not well-defined with scanty reports. We describe a new method of urethroplasty for the repair of female urethral stricture. MATERIALS AND METHODS: Three 60-year-old females, each with a history of recurrent urinary tract infections and obstructive voiding symptoms due to urethral stricture, underwent urethroplasty with a dorsal vaginal or buccal mucosal graft. The dorsal aspect of the distal urethra was dissected from the surrounding tissue through a suprameatal incision and the urethral wall was incised through the stricture at the 12 o'clock position. A 1.5 cm wide free graft was harvested from the vaginal wall or buccal mucosa in 1 case, and the mucosal surface was placed upon the urethral lumen and sutured with a running 5-zero polyglactin suture to the open urethra. Indwelling 18Fr urethral and 16Fr suprapubic catheters were left in place for 2 and 3 weeks, respectively. RESULTS: No additional treatment was required during the 1, 8 and 27 months of followup. All patients had normal micturition following catheter removal. CONCLUSIONS: Dorsal graft urethroplasty is feasible and effective for the correction of persistent female urethral stricture.     

Combined Dorsal and Ventral Buccal Mucosal Graft Urethroplasty by Unilateral Mobilisation of Urethra with Single Dorsal Urethrotomy Incision in Long Segment Anterior Urethral Strictures

The aim of this study is to evaluate the outcomes of combined dorsal and ventral buccal mucosal graft urethroplasty by unilateral mobilisation of urethra with single dorsal urethrotomy incision in long and narrow anterior urethral strictures with preserving the narrow urethral plate and blood supply. Between June 2012 and July 2016, 26 men with long anterior urethral strictures underwent urethroplasty by our technique in a tertiary care teaching hospital. The urethra was mobilised only one side. Then, it was opened in the dorsal midline over the stricture. The first graft was secured on the tunica of the corporal bodies. Thereafter, the diseased mucosa on the ventral side of the urethra was excised and the second graft was placed as ventral inlay and fixed to the corpus spongiosum. The cut edges of urethra were closed by suturing to dorsally placed graft. Successful urethral reconstruction was defined as normal voiding without the need for any postoperative procedure. Mean follow-up was 36 months and mean stricture length was 4.29 cm. Of these 26 cases, 23 (88.4%) were successful and 3 (11.53%) were treatment failures with restricture. The combined dorsal plus ventral buccal mucosal graft urethroplasty by unilateral mobilisation of urethra with single dorsal urethrotomy incision provides adequate urethral augmentation by preserving urethral vascularity and the narrow strip of urethral plate in long and tight anterior urethral strictures.     

结肠粘膜重建尿道的实验研究

目的：探讨结肠粘膜重建尿道的可能性。方法：选择6条雌性杂种成年犬，在全麻下切开尿道，剥离全段尿道粘膜，取相等长度的结肠粘膜替代尿道粘膜，12周后将犬处死，取其尿道作病理检查。结果：犬尿道病理组织学检查示移植于尿道的结肠粘膜全部成活，大部分腺上皮已转变为移行上皮。结论：应用结肠粘膜重建尿道是一种新的方法，这种技术可应用于包皮或膀胱及颊粘膜不适合时的尿道重建。     

The buccal mucosal graft for urethral reconstruction: a preliminary report.

Autologous buccal mucosa as a substitute for urethral epithelium was studied in 2 dogs and used in 6 patients with difficult urethral reconstruction problems. The indications for an operation in these patients were failed hypospadias repairs with limited skin in 3, severe structure disease after hypospadias repair in 1, a short urethra in 1 and epispadias in 1. Three urethral fistulas and 1 meatal stenosis occurred in 3 patients. No urethral stricture or diverticulum was noted, and the final outcome was good functionally and cosmetically in all patients. This technique is useful for urethral reconstruction when local skin is not available.     

Long-term followup of the ventrally placed buccal mucosa onlay graft in bulbar urethral reconstruction

PURPOSE: We investigate whether the short-term success rate (greater than 90%) of buccal mucosa free grafts in the bulbar urethra is sustained in the long term. MATERIALS AND METHODS: In 60 patients a ventrally placed buccal mucosa graft was used for repair of bulbar urethral strictures. Of these patients 49 had undergone previous attempt at repair (urethroplasty in 4, internal urethrotomy in 45). Mean graft length was 4.8 cm. In 9 patients a distal penile fasciocutaneous flap was also used for repair of concomitant penile urethral stricture. In 8 of the 9 patients the buccal mucosa graft was combined with end-to-end urethroplasty and 2 buccal mucosa grafts were used in tandem in 1. Followup was at least 1 year in all cases (mean 47 months, range 12 to 107). Failure was defined as an obstructive voiding pattern with radiographic or cystoscopic evidence of recurrent stricture. RESULTS: Bulbar stricture repair was successful in 54 patients (90%) and 4 of the remaining 6 responded to 1 internal urethrotomy for a long-term success rate of 97%. Preoperative clinical characteristics were not significantly different between those who experienced success or failure. CONCLUSIONS: Long-term outcome analysis of ventrally placed buccal mucosa onlay grafts for bulbar urethral strictures demonstrates a durable success rate of 90%. This rate can be improved (97%) with the judicious use of internal urethrotomy.     

Two‐stage repair with buccal mucosa for severe and complicated hypospadias in adults

Objectives: To report the outcomes of two‐stage repair for adult hypospadias using a buccal mucosa graft as a tube. Methods: A total of 57 adult patients who underwent surgery for severe urethral defect at our institution from January 2002 to March 2010 were included in this analysis. The urethroplasty procedure included penile urethra reconstruction with the buccal mucosa graft used as a tube in the first stage, anastomosis of the unobstructed urethra in the second stage and a scrotal fascio‐cutaneous flap transferred to resurface the reconstructed urethra for waterproofing. Results: No complications occurred after the first stage, whereas postoperative infections occurred in six cases and distal necrosis of the scrotal flap occurred in two cases after the second stage. All eight of these patients had the complication of urethrocutaneous fistula, which healed after 2–4 weeks by cleaning and changing dressings in six patients. Twelve patients complained of straining at voiding in the early postoperative period. However, nine of these patients had an obvious increase in maximum flow rate without any intervention 3 months after the operation. Follow up ranged from 6 to 62 months (mean 28 months) in 46 patients. Most of the patients presented terminal meatus, no chordee, no urethral stricture and normal voiding. The majority of patients achieved excellent cosmetic and functional results. Conclusions: A buccal mucosa graft as a tube is a reliable and durable method of two‐stage repair for severe and complicated hypospadias in adults. The use of scrotal flaps seems to contribute to a good vascularized waterproof cover.     

Combined bladder neck, urethral and penile reconstruction in boys with the exstrophy-epispadias complex

OBJECTIVE: To describe a one-stage combined bladder neck, urethral and penile reconstruction for achieving urinary continence and creating a penis with good cosmesis and function in boys with the exstrophy-epispadias complex. PATIENTS AND METHODS: Seventy-three boys underwent the combined procedure, including 36 after classic bladder exstrophy closure and 37 with epispadias. All were completely incontinent at the time of combined reconstruction. The bladder capacity just before surgery was 70-180 mL and was greater in those with epispadias. The boys were 2.5-11 years old, with those in the exstrophy group being slightly older. RESULTS: Thirty-three boys (89%) with epispadias were completely continent during the day but 15 had episodes of nocturnal enuresis. Of boys with classic exstrophy, 27 (75%) were continent during the day but nine had occasional nocturnal enuresis. Eleven boys required intermittent catheterization, which they found easy to perform. In seven boys (10%) a urethrocutaneous fistula or urethral stricture developed. CONCLUSIONS: Combined bladder neck, urethral and penile reconstruction can be carried out as a one-stage procedure in selected patients with adequate bladder capacity. Reconstruction of the whole length of the urethra facilitates intermittent catheterization.     

犬舌黏膜与颊黏膜组合移植重建尿道的实验研究

目的 探讨犬舌黏膜与颊黏膜组合移植替代尿道的可行性和有效性. 方法杂种雌犬7只,平均体质量13 kg,剥离尿道黏膜4 cm×1 cm,取2 cm×1 cm舌侧面黏膜和颊黏膜各1条,拼接后移植至尿道内,恢复尿道黏膜的连续性.术后留置硅胶导尿管1周,拔除尿管后观察排尿情况.1.5～12.0个月后行逆行尿道造影检测实验犬尿道通畅情况,并用10 F尿管证实有无狭窄.随后处死实验犬,测定移植物长度并行病理组织学检查,观察舌黏膜与颊黏膜组合移植至尿道后组织学改变情况. 结果7只实验犬均存活,排尿通畅6只,发生尿道狭窄1只;无尿瘘.移植手术前后舌黏膜和颊黏膜拼接长度分别为(4.00±0.15)和(3.75±0.23)cm,差异有统计学意义(P＜0.05).排尿通畅犬移植黏膜存活良好;舌黏膜与颊黏膜交界处愈合良好,无狭窄发生;光镜下见鳞状上皮呈连续分布,拼接移植黏膜的鳞状上皮与尿道的移行上皮区分明显,移植黏膜的鳞状上:皮有渐被尿道移行上皮替代的趋势.结论 犬舌黏膜和颊黏膜组合移植可替代尿道黏膜并恢复尿道的连续性.     

8 cm以上复杂性尿道狭窄的外科治疗

目的探讨长段尿道狭窄手术方法的选择与疗效。方法对76例尿道狭窄8cm以上的患者采用不同尿道成形术式治疗,其中不同黏膜重建尿道42例（结肠黏膜26例,膀胱黏膜6例,口腔黏膜10例）;带蒂皮瓣一期尿道成形20例;尿道狭窄段切开、二期尿道成形（Johanson术）12例;阴茎段尿道与前列腺部尿道吻合、三期尿道成形术2例。结果术后初期（6个月内）排尿通畅67例（88％）,有并发症者10例。术后1年以上70例,其中获得随访51例,排尿通畅44例,有并发症者8例,其中采用带蒂皮瓣者发生尿道狭窄2例（18％,2／11）;Johanson术者发生阴茎弯曲2例（2／5）,其中1例成形段尿道内毛发生成和结石形成;采用口腔黏膜者发生尿道狭窄1例（1／7）,膀胱黏膜者发生尿道狭窄1例（1／3）,结肠黏膜者发生后尿道狭窄2例（9％,2／23）。结论口腔与结肠黏膜尿道成形对长段尿道狭窄是较理想的术式;结肠黏膜较适合在常规手术治疗失败后或复杂性尿道狭窄10cm以上的治疗。