保留尿道板手术在尿道下裂治疗中的应用

目的：探讨保留尿道板手术在尿道下裂的疗效，方法。总结分析189例保留尿道板的尿道下裂修复手术。结果：保留尿道板手术总成功例数177／189（93．65％），其中采用尿道口基底皮瓣法（Mathieu法）39／42例（92．86％），加盖岛状皮瓣法(Onlay island flap法）138／147例（93．88％），结论：保留尿道板手术适用于无或伴有轻度阴茎下弯的尿道下裂治疗，可按尿道口位置选择手术方法：冠状沟型及阴茎体前型尿道下裂采用Mathieu法，阴茎体型及阴茎根型尿道下裂采用Onlay island flap法。     

尿道下裂手术方法选择再认识

目的 探讨不同类型尿道下裂手术方法的选择。方法 总结2000-2003年治疗490例尿道下裂的临床经验。无阴茎下弯或轻度阴茎下弯通过阴茎背侧白膜折叠矫正后的尿道下裂手术方法，包括：尿道口位于舟状窝患儿选用尿道口前移、阴茎头成型(MAGPI)；尿道口位于阴茎体、阴茎根患儿用加盖岛状包皮瓣法(Onlay)；Snodgrass法用于尿道板发育好的远端前型尿道下裂以及部分再次手术病例；合并阴茎下弯的尿道下裂应用带蒂岛状包皮瓣尿道成型术(Duckett)及Duckett Duplay术式。结果 各种手术方法的成功率：MAGPI为95．5％(21／22例)；Snodgrass 93．3％(14／15例)，Snodgrass用于再次手术的患儿效果72.4％(21／29例)；Onlay 95．5％(213／223例)；Duckett 90．8％(157／173例)；Duckett Duplay 81．6％(31／38例)。结论 应根据尿道下裂有无合并阴茎下弯及尿道开口位置和阴茎发育的状况选择手术方法。     

应用Snodgrass尿道成形术治疗远端尿道下裂

目的探讨Snodgrass尿道成形术治疗远端尿道下裂的体会。方法2001-2005年应用Snodgrass尿道成形术治疗146例尿道下裂。年龄1～16岁，平均3岁。其中治疗首诊病例62例；治疗已经过手术修复失败的病例84例。在同期，修复远端尿道下裂应用最多的是加盖岛状皮瓣法（onlay island flap法），共266例。结果首诊Snodgrass手术62例，成功57例（91．9％），2例尿道狭窄，3例尿道瘘。对失败的尿道下裂病例应用Snodgrass手术84例，成功64例（76．2％），尿道瘘14例，尿道狭窄6例。Onlay手术266例，成功256例（96．2％），尿道瘘10例。结论Snodgrass尿道成形术适合尿道板发育好的无阴茎下弯的远端尿道下裂病例，以及部分失败的尿道下裂修复、长段尿道瘘病例。尿道板发育差的病例适合Onlay手术。     

尿道下裂术后严重并发症的治疗体会

探讨尿道下裂术后严重并发症的处理途径。方法收治尿道下裂术后严重并发症１３例,分别采用三种不同的处理方法：（１）简单尿瘘修补和／或尿道狭窄处切除吻合２例;（２）彻底切除阴茎腹侧瘢痕组织和病变尿道,充分矫正阴茎下曲后同时重建尿道４例;（３）彻底切除阴茎腹侧病变组织,充分伸直阴茎、尿道后移造口,二期重建尿道７例。     

Combined use of perimeatal-based flap urethroplasty (Mathieu) with midline incision or urethral plate in hypospadias repair.

Perimeatal-based flap urethroplasty is commonly used for the primary correction of distal hypospadias. The Mathieu repair provides excellent function and satisfactory cosmetic results, but the risk of devascularisation of the neourethral flap is an inherent problem of this technique. The midline incision of the urethral plate is part of the Snodgrass method, which offers good urethral calibre and tension-free closure. Our aim was to test the effectiveness of the use of the perimeatal-based flap combined with a midline incision of the urethral plate in hypospadias repair. 19 boys, aged 20 months to 5 years, with distal hypospadias, underwent a one-stage repair using the above-described modification of the Mathieu technique. The meatal-based flap with a midline incision of the urethral plate was similar in all cases. The hypospadias repair was successful in all patients, only one boy developed a urethrocutaneous fistula which required subsequent operation. There was no postoperative scarring, chordee or urethral stricture during follow-up. Hypospadias repair using a perimeatal-based skin flap and combined with an incision of the urethral plate reduces complication rates and offers good cosmetic results.     

The Mathieu Righini technique for mid-distal hypospadias repair

In a series of 1,989 operated cases of hypospadias, the technical details, precise indications, and results in 408 consecutive cases of distal and mid-penile hypospadias without chordee using the one-stage Mathieu-Righini procedure are described. This technique employs a meatal flap in which the prepuce is preserved and reconstructed. Twelve fistuals occurred, the majority in the initial phase of the experience, and 2 cases of meatal stenosis were easily managed by dilations. The overall complication rate was 3.4%. This technique provides very good cosmetic and functional results: the penis is normal in appearance as well as function. In the author's opinion, the Mathieu-Righini technique is the procedure of choice for mid-distal hypospadias without chordee repair.     

精索外筋膜联合唇黏膜移植一期修复尿道下裂修复失败的初步报告

目的通过预置精索外筋膜改良唇黏膜移植的方法,同期联合局部皮瓣尿道成形一期修复术治疗手术修复失败的尿道下裂,并评价其疗效。方法2014年12月至2017年4月作者采用预置精索外筋膜移植床一期治疗13例修复手术失败的尿道下裂患儿,年龄2.5~6岁,患儿至少经历1次失败的尿道下裂手术,阴茎体与睾丸大小、质地均尚可,术前合并不同程度阴茎弯曲。沿原手术切口暴露原手术建立的尿道,人工勃起试验均提示存在阴茎体下弯(弯曲15°~45°)。自腹侧弯曲最显著处完全离断原尿道海绵体,深达阴茎海绵体白膜后完全伸直阴茎,剔除白膜表面原手术后瘢痕组织,尿道缺损长度2.2~4.9 cm;于一侧睾丸鞘膜表面自睾丸底部到腹股沟管处解剖长段精索外筋膜后,将其转移覆盖于白膜表面尿道缺损处,取同等长度的下唇黏膜移植于精索外筋膜表面,固定后游离局部带蒂阴茎皮肤加盖成型新尿道,一期完成重建手术。结果13例患儿留置导尿管3周后拔除,随访12~40个月后,2例出现尿道瘘(1例位于冠状沟、1例位于阴茎根部),均再次行手术修补;1例阴茎头裂开未予处理,1例尿道外口狭窄行尿道外口扩张后治愈。所有患儿阴茎勃起时无下弯,患儿家长对其术后阴茎体外观满意。结论通过预置精索外筋膜可增加唇黏膜的获取率,有效避免移植物挛缩的问题,可一次性完成尿道重建手术。     

尿道口基底两侧包皮瓣Ⅰ期尿道成形术修复近端型尿道下裂

目的 探讨尿道口基底两侧包皮瓣Ⅰ期尿道成形术修复近端型尿道下裂的临床效果.方法 本组53例,年龄为4.5(2～13)岁.采用尿道口基底两侧和背部的包皮瓣与尿道板联合卷管成形新尿道.结果 其皮瓣长度平均为4.1(2.5～9.0)cm.术后尿液引流时间平均10.9 d(7～14 d).37例获随访6个月以上.Ⅰ期手术成功44例(83.0%).并发症:尿瘘6例,尿道狭窄2例,尿道憩室1例均需再次手术.尿道外口狭窄1例经尿道扩张后治愈.再次手术成功率为77.8%(7/9).随访:外观佳的占86.5%(32/37);梗阻型尿流曲线为:35.5%(11/31).结论 该术式符合解剖生理,对Ⅰ期修复近端型尿道下裂是一种较理想的手术方式.

Abstract：

Objective To report the of treatment of proximal hypospadias with one-stage urethroplaty with two laterally-based flaps. Methods Fifty-three patients (mean age, 4. 5 years; age range:2-13 years) with hypospadias and severe chordee were operated. Neourethra was formed with tabularized meatal based paracoronal skin flaps and urethral plate. The neourethral flap was 2.5-9 cm (mean 4. 1 cm) in length. The catheters were removed 7-14 days (mean 10. 8 days) post-operately.Thirty-seven patients were followed up more than 6 months. Results Successful one-stage repair was achieved in 44 cases (83. 0%). Fistula developed in 6 patients, urethral stricture in 2 patients, urethral diverticulum in 1 patient which required re-operation. Meatal stenosis developed in 1 patient. The reoperation success rates were 77. 8% (7/9). Good post-operative cosmetic appearance of penis was achieved in 86. 5% of patients (32/37). A plateau uroflow curve (vs normal bell curve) was observed in 35. 5% (11/31) of patients. Conclusions The technque was based on the applied anatomy. It offers a good alternative for proximal hypospadias.     

横裁岛状包皮皮瓣一期修复尿道下裂的经验

目的总结横裁岛状包皮皮瓣法修复先天性尿道下裂的经验。方法对1999年-2005年我科56例采用横裁岛状包皮皮瓣法进行尿道成形的尿道下裂患儿进行回顾性分析。其中5例加用尿道口为基底的阴囊矩形皮瓣作Duplay尿道成形。结果本组病例均获随访,时间3个月-4年,阴茎外观良好,阴茎下弯矫正满意,排尿通畅。一次手术成功49例,占89．3％;术后尿瘘5例,经第二次手术修补后痊愈,尿道狭窄1例,经尿道扩张后排尿改善。结论横裁岛状包皮皮瓣符合阴茎皮肤的解剖生理特点,设计合理,采用吻合口连续缝合,更加降低了尿瘘的发生率,避免耻骨上造瘘及带来的膀胱损伤。对多数尿道下裂尤其是有阴茎下弯的尿道下裂,采用横裁包皮岛状皮瓣法并灵活加用尿道口基底矩形皮瓣是一个很好的选择。     

阴囊纵隔带蒂皮管法Ⅰ期尿道成形术(附121例报告)

目的 介绍应用阴囊纵隔带蒂皮管法治疗儿童先天性尿道下裂的经验。方法 尿道下裂121例，手术矫正阴茎下弯后，于尿道口近端取宽1cm～1．5cm的带血管蒂皮瓣，包绕硅胶管用可吸收线连续缝合成新尿道。结果 手术121例，成功107例，成功率为(88．5％)。术后尿瘘14例，尿道狭窄5例，憩室3例，尿道内毛发2例，尿道内结石1例。结论 阴囊纵隔皮管法尿道成形术皮瓣血运好，易成活，成功率高，操作简单，容易掌握，适合于矫正阴茎下弯后尿道口位于阴茎根部或阴茎阴囊交界型尿道下裂。但术后阴茎外观不十分满意且有尿道长毛发和结石可能，故选用此法应综合多方面因素考虑。     

加盖带蒂包皮瓣一期尿道成形术修复小儿尿道下裂

目的：探讨加盖带蒂包皮瓣Ⅰ期尿道成形术修复小儿尿道下裂的手术要点和临床效果,提高手术技巧。方法对50例小儿尿道下裂应用onlay island flap术式（横裁带蒂岛状包皮瓣加盖法）行一期尿道成形手术。观察阴茎伸直和尿瘘、尿道狭窄的发生情况,总结和完善手术技巧。结果50例手术患儿获随访3个月至2年,均阴茎伸直满意,尿道位于龟头前端开口,外观良好。44例尿道下裂一次性手术成功,4例发生尿瘘;2例发生尿道外口狭窄,行尿道扩张后痊愈。结论加盖带蒂包皮瓣Ⅰ期尿道成形术修复小儿尿道下裂符合解剖生理,术后阴茎外形美观,并发症少,是一种修复阴茎下弯较轻的尿道下裂的理想术式。手术成功的关键在于保护皮瓣血管蒂的血供,掌握合理的尿道板皮条和岛状包皮瓣宽度及娴熟的缝合技巧。     

Outcome analysis of tubularized incised urethral plate using dorsal dartos flap for proximal penile hypospadias repair

PurposeTo assess the outcome of tubularized incised plate (TIP) urethroplasty in conjunction with a dorsal dartos flap for primary proximal penile hypospadias.Materials and methodsForty-nine patients with proximal penile hypospadias underwent a one-stage TIP urethroplasty with single-layer closure using polyglactin suture. A dorsal dartos (subcutaneous) flap, harvested from the dorsal penile shaft was used to cover the neourethra ventrally. Glanuloplasty was also performed in all cases. All patients had a well preserved urethral plate after straightening of the penis. Complications and cosmetic appearance were documented during follow-up.ResultsMean patient age at surgery was 23 months (16–72 months). Mean operative time was 180 min (154–240 min). At the mean follow-up of 36 months, the overall complication rate was 12% (4 fistulae, 1 meatal stenosis). Glandular dehiscence occurred in one patient, and 38 patients (78%) required dorsal Nesbit plication. No patient had residual chordee, neourethral stricture or a urethral diverticulum, and the neomeatus with a slit-like appearance was positioned at the glans tip.ConclusionsTIP urethroplasty with dorsal dartos layer covering the neourethra is an effective treatment for primary proximal penile hypospadias with a preserved urethral plate and without severe curvature. There is a good cosmetic outcome with low risk of complications.     

One-stage repair of severe hypospadias using modified tubularized transverse preputial island flap with V-incision suture

PurposeAlthough hypospadias repair for preserving the urethral plate is popular among pediatric urologists, applying this procedure to severe hypospadias is controversial. We report the outcome of applying additional modifications to the modified tubularized transverse preputial island flap (TPIF) procedure reported previously [Patel RP, Shukla AR, Austin JC and Canning DA. Modified tubularized transverse preputial island flap repair for severe proximal hypospadias. BJU Int 2005;95:901–4] for repairing severe hypospadias.Materials and methodsWe retrospectively evaluated our series of 22 patients (mean age 17.5 months) who underwent the modified TPIF with an additional simple modification of meatoplasty with V-incision suture. Patients were followed for a mean period of 18 months.ResultsAfter releasing the chordee, the hypospadiac orifice was retracted to become penile in five patients (22.7%), penoscrotal in six (27.3%), scrotal in nine (40.9%), and perineal in two (9.1%). The median length of the neourethra was 46 mm. One-stage repair was successful in 19 patients (86.4%) without any complications.ConclusionOur modified TPIF procedure yielded favorable outcomes functionally and cosmetically with a low postoperative morbidity rate. Such a procedure can be considered useful for repairing severe hypospadias when the urethral plate cannot be preserved.     

Evaluation of Onlay Island Flap Technique in Shallow Urethral Plate Hypospadiasis

Background:

Hypospadias is one of the most common congenital genital anomalies in males that necessitates to be operated early in infancy (when 6 to 9 months old). On the other hand, hypospadias is a challenging field of pediatric urology with multiple reconstruction techniques. A perfect hypospadias repair is supposed to return urethral continuity with sufficient caliber, eradicate phallus curvature, and supply an acceptable appearance with low complications.

Objectives:

This study aimed to evaluate the outcomes of using onlay island flap technique in the repair of hypospadias with shallow urethral plate.

Patients and Methods:

In this prospective study within June 2012 to December 2013, we performed onlay island flap procedure to repair hypospadias with shallow urethral plate measuring less than 6 millimeter. This technique was selected for all types of hypospadiasis except subcoronal type. Nesbit’s dorsal plication procedure was established for chordee. In cases with very small glans, urethroplasty was performed without glansplasty.

Results:

Twenty three patients with mean age of 30 (range 10 - 60) months underwent onlay island flap repair; all had a shallow urethral plate < 6 mm, 3 had a very small glans, and 18 had chordee. Meatus was located in distal shaft in 5 cases, mid shaft in 8, proximal in 6 and penoscrotal type in 4 patients. Chordee was corrected with Nesbit’s dorsal plication in 16 cases. Complications were: meatal stenosis in 2 cases and urethrocutaneous fistula in 2 patients, all of which were repaired surgically. Mean follow up time was 13 (3 - 20) months. All cases that had glansplasty have excellent esthetic appearance.

Conclusions:

This technique offers acceptable results regarding meatal stenosis, urethrocutaneous fistula and esthetic outcome.     

带蒂管状岛状包皮瓣尿道成形术在尿道下裂修复中的应用

目的 评价带蒂管状岛状包皮瓣尿道成形术在尿道下裂病例修复中的应用.方法 回顾性总结2006年1月至2008年12月应用Duckett与Duckett+Duplay手术558例经验.患儿年龄1～8岁,平均年龄3.4岁.其中Duckett法457例,Duckett+Duplay法101例.结果 手术后随访12～36个月.Duckett手术457例,一次性手术成功336例,成功率73.5%,并发症121例:其中尿道瘘61例;尿道憩室42例;尿道狭窄10例;尿道瘘合并尿道憩室8例.行Duckett+Duplay手术101例,成功率73.3%,并发症27例:尿道瘘13例;尿道憩室5例;尿道狭窄6例;尿道瘘合并尿道憩室3例.以上两组手术结果比较差异没有统计学意义(P＞0.05).Duckett手术后并发症121例,有108例经一次修复痊愈,12例修复两次后痊愈,1例尿道狭窄经三次修复痊愈.Duckett+Duplay手术后并发症27例,18例一次修复痊愈,9例修复两次后痊愈.结论 带蒂管状岛状包皮瓣尿道成形术治疗尿道下裂效果比较满意.     

Observational retrospective study on acquired megalourethra after primary proximal hypospadias repair and its recurrence after tapering

IntroductionAcquired megalourethra (AMU) after repair of proximal hypospadias can be a serious complication. An observational retrospective study of its incidence among different types of repair was performed.Materials and methodsClinical charts of patients operated on for proximal hypospadias were reviewed. Inclusion criteria: all primary hypospadias operated in 1991–2004, with the meatus positioned in proximal penile, scrotal or perineal position.ResultsOf 770 hypospadias cases treated, 130 (16%) were proximal. Seventy-two patients (55%) were treated using preputial flaps: 36 with a tubularized preputial island flap (TIF) and 36 an onlay island flap (OIF). Fifty-eight patients (45%) underwent staged repairs: Belt-Fuquà (BF) in 18 and Bracka procedure in 40 cases. After a mean follow up of 16 years (range 6–19) the overall incidence of complications for each technique was: TIF 36%; OIF 33%; BF 25%; two-stage Bracka 7.5%. The most common complication encountered was neo-urethral fistula. AMU occurred in only 5 cases, none with associated distal urethral stenosis, all in the TIF and OIF groups, and all successfully treated by reduction re-do urethroplasty.ConclusionA very small number of the patients operated using preputial island flaps techniques developed AMU. None of the staged repairs developed AMU, and this is the preferred choice in proximal hypospadias when the urethral plate requires division and/or substitution. All cases of AMU resolved after urethral tapering.     

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.     

分期Duckett术式治疗重度尿道下裂的疗效评价

目的：通过与一期 Duckett 术式手术效果进行比较,探讨分期 Duckett 术式治疗重度尿道下裂的应用及价值。方法2009年1月至2014年10月,我们收治重度尿道下裂72例,均为阴茎阴囊交界型或会阴型尿道下裂,患儿第1次手术时年龄2～3岁,平均2.4岁。其中38例采用管形包皮岛状皮瓣法一期尿道成形术,即一期 Duckett 术式,为 A 组,成形尿道长度4～6 cm。34例采用分期手术,一期手术中矫正阴茎下弯后,采用管形包皮岛状皮瓣法成形部分尿道,即分期 Duckett 术式,为 B 组;第一期成形尿道长度为3～4.5 cm;术后1年行二期尿道成形术,成形尿道长度1.5～2.5 cm,两期手术成形尿道总长度4～6 cm。结果两组均获随访,术后随访6个月至5年,平均3.5年,无一例阴茎下弯复发。A 组有7例（7／38,18.5％）术后发生尿瘘。B 组有3例（3／34,8.8％）术后发生尿瘘,均出现在二期尿道成形术后。A 组有4例出现尿道狭窄（4／38,10.5％）,B 组1例出现尿道狭窄（1／34,2.9％）。A组有4例出现尿道憩室（4／38,10.5％）,B 组无一例尿道憩室发生。A 组手术成功率为60.5％,B 组手术成功率为88.3％,差异有统计学意义（P ＝0．008）。结论与一期 Duckett 术式相比,分期 Duckett术式治疗重度尿道下裂,术后并发尿瘘、尿道狭窄和尿道憩室少。分期 Duckett 术式有效降低了重度尿道下裂的手术难度和并发症的发生率,提高了复杂尿道下裂的疗效,具有较好的临床应用价值。     

The extended Mathieu procedure in coronal,distal penile,and midshaft hypospadias repair

The Mathieu procedure was adequately modified for glanular, coronal, and midshaft hypospadias variants with chordee and/or urethral hypoplasia in order to anatomically reconstruct the penis. A total of 129 patients aged 12 months to 22 years with coronal (35.7%), distal penile (51.9%), and midshaft (12.4%) hypospadias were operated upon. Chordee was found in 33.3% and distal urethral hypoplasia in 15.5% of the patients. The ventral flap was based anatomically on the external meatus, the glans was made pyramidal with an apical external meatus, the prepuce was resutured, and the neurethra was buried deeply within the glans. In patients with distal urethral hypoplasia the external meatus was incised proximally; in chordee the urethral plate was mobilized off the corpora cavernosa. Fistulas were uncommon (3.4%) in the primarily operated patients. The external meatus was always apical, and no stenosis was demonstrated at follow-up. The prepuce was reconstructed in 71.5% of patients. The extended Mathieu procedure appears recommendable for all coronal, distal penile, and midshaft variants regardless of associated anomalies of the penis. It also seems suitable for secondary repairs. The prepuce can be reconstructed in the majority of patients. The complication rate is significantly low compared to other methods, and the extended Mathieu operation is a good teaching tool with a high success rate and versatility.     

冠状沟型尿道下裂一期修复术

目的 提出冠状沟型尿道下裂一期手术新术式。方法 应用包皮和阴茎皮肤联合皮瓣成形尿道，利用原龟头裂与包皮皮瓣成形尿道外口。结果 临床应用２０例，一次手术成功１９例，１例并发尿道瘘。结论 本法成形尿道皮瓣血运良好，不易发生皮瓣坏死，并发症少。利用龟头裂成形尿道外口，避免了尿道外口狭窄，术后尿道外口位于龟头顶端，阴茎外形接近于正常。