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。     

Snodgrass hypospadias repair with onlay overlapping double-layered dorsal dartos flap without urethrocutaneous fistula: Experience of 156 cases

ObjectiveTo evaluate the neourethra covering created by a vascularized overlapping double-layered dorsal dartos flap for preventing urethrocutaneous fistula in the Snodgrass hypospadias repair (tubularized incised plate).Patients and methodsBetween March 2003 and January 2008, 156 boys (mean age, 4.5 years) were enrolled for hypospadias repair. Preoperative position of the urethral meatus was subcoronal in 37, at the distal shaft in 61 and mid-shaft in 58 boys. All patients underwent the Snodgrass hypospadias repair. The neourethra was then covered with an overlapping double-layered dorsal dartos flap before glans and skin closure.ResultsAll 156 patients underwent successful reconstruction. With a mean follow up of 23 months (range 6–42), all boys had a satisfactory subjective cosmetic and functional result with a vertically oriented, slit-like meatus at the tip of the glans. No urethrocutaneous fistula or urethral stenosis occurred.ConclusionAs the neouretha covering is an integral part of the Snodgrass hypospadias repair, a dorsal well vascularized double-layered dartos flap is a good choice for preventing urethrocutaneous fistula formation.     

The midterm success rates of tubularized incised plate urethroplasty in reoperative patients with distal or midpenile hypospadias

To review the midterm results of tubularized incised plate (TIP) urethroplasty (Snodgrass method) in reoperative patients with distal or midpenile hypospadias. The results of TIP urethroplasty in 37 patients who had previously failed hypospadias repair were reviewed. Of the patients, 21 (56.8%) had coronal, 11 (29.7%) had subcoronal, and 5 (13.5%) had midpenile hypospadias. The mean age was 4.1 (2–16) years. Twenty-three patients had one operation and 14 patients had two operations previously. Of all the patients, 14 did not have a foreskin because of circumcision. The urethral plate had been disturbed in 6 patients, but there was not apparent scarring of the plate. Postoperative follow-up was 2.3 years with a range of 1.1–3.9 years. Genital examination, urethral calibration, and uroflowmetry were performed in control. Satisfaction of the families about the function and appearance of penis was also evaluated. Successful functional and cosmetic results were achieved in 29 patients (78.4%). All the families were happy with penile aesthetic appearance. The urethral plate seemed healthy at the operation in nine patients who had undergone TIP urethroplasty before and the outcomes were successful in eight of them. The operation was successful in 19/23 (82.6%) patients who had undergone one operation before and in 10/14 (71.4%) patients with two operations as well (P<0.05). In addition, sufficient outcomes were obtained in also 11 of the 14 patients with circumcision. The success rate was higher in patients <5 years (P<0.05). The rate was also higher during the recent period (2001–2003) since the experience we had increased (P<0.05). TIP urethroplasty was unsatisfied in four of the six patients who had had disturbed urethral plate before and in five of eight patients who did not have sufficient amount of dartos tissue for flap to cover neourethra. Complication was observed in eight patients (21.6%): four had a pinpoint fistula, two had wound dehiscence, one had meatal stenosis, and one had mild meatal regression and a short neourethral stricture. All of these complications were repaired successfully at a later date. The mean hospital stay was 4.6 days. TIP urethroplasty provides good functional and cosmetic midterm outcomes in most of the reoperative patients with distal or midpenile hypospadias unless contraindicated by previous resection or gross scarring of the urethral plate. This procedure seems not to disturb the urethral plate and, therefore, it can be applied on reoperative patients who had undergone TIP urethroplasty before. It can also be used in a circumcised patient when there is a lack of foreskin.     

尿道板纵切卷管尿道成形术治疗小儿尿道下裂

目的 评价尿道板纵切卷管尿道成形术(Snodgrass手术)治疗尿道下裂的疗效。方法 总结了2年间21例行Snodgrass手术的尿道下裂患儿的手术资料。患儿年龄2～12岁，平均6．2岁，其中阴茎头型3例，阴茎体型17例，阴囊型1例。结果 手术治愈19例(90．5％)，有2例患儿发生尿瘘，尿瘘发生率为9．5％，2例尿瘘患儿半年后再行Snodgrass手术，均获得成功，无尿道狭窄发生。结论 Snodgrass手术保留了尿道板，操作简单，手术时间短，仅40min；并发症较少；手术成形效果好；对于首次手术失败后再次尿道成形效果良好，是适用于各型尿道下裂治疗的较好方法。     

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。     

Evaluation of the results of eccentric circummeatal-based flap with combined limited urethral mobilization technique for distal hypospadias repair

ObjectiveTo evaluate the outcome of patients with distal hypospadias who are operated using the eccentric circummeatal-based flap (ECBF) with combined limited urethral mobilization (LUM) technique.Patients and methodsWe retrospectively reviewed the medical records of all patients who underwent distal hypospadias repair at our institution between January 2000 and December 2005. Seventy-one patients with distal hypospadias were operated. Eighteen cases were operated with glanular approximation and 11 cases using the Snodgrass procedure. Forty-two cases of distal hypospadias without a thin distal urethra were operated using an eccentric circummeatal-based flap with combined limited urethral mobilization. We reviewed these 42 patients according to age at surgery, position of meatus, presence of ventral curvature or glanular tilt, previous operations, duration of catheterization and hospitalization, and early and late postoperative complications.ResultsThe mean age at operation was 5.9 ± 3.1 years. The position of the meatus was coronal in 29 patients (69%), glanular in seven (16.7%) and subcoronal in six (14.3%). Two patients had ventral curvature. Five patients had undergone previous unsuccessful hypospadias repair and five had undergone circumcision. The average length of catheterization was 4.64 ± 1.07 days. All patients were discharged after stent removal. At follow up of 1–31 months (median 6 months, 22 patients over 6 months), three patients had a slightly glanular urethral meatus and six patients had a decrease in calibration during urination which responded to meatal dilatation. No fistula had occurred. All patients achieved a normally situated vertical slit-like glanular meatus.ConclusionThis technique is simple with satisfying cosmetic results, and can also be applied to patients who have undergone previous failed operations. The absence of fistula formation and short duration of hospital stay are additional advantages.     

巨尿道口伴完整包皮(MIP)型尿道下裂的认识和处理

目的 探讨巨尿道口伴完整包皮型尿道下裂的认识和处理.方法 回顾性分析2004年7月至2010年2月同一治疗组收治的巨尿道口伴完整包皮型尿道下裂病例.本组13例,年龄4岁5个月至12岁1个月,平均8岁1个月.就诊原因包括尿道口位置异常2例、阴茎外观短小1例、包茎10例.尿道开口于冠状沟3例,开口于阴茎远段10例.10例行尿道板纵切卷管尿道成形术(TIP)尿道成形,3例行Duplay尿道成形.术后随访3～45个月,平均9个月.结果 9例患儿成形尿道0.5～1.3 cm,平均0.9cm.术后尿瘘1例,再次手术矫治满意.其余病例外观满意,呈包皮环切术后外观,尿流尿线正常.结论 MIP型尿道下裂常因包茎手术时发现,阴茎弯曲多不明显,矫治时可保留尿道板,Duplay或TIP手术矫治效果满意.     

MAGPI procedure in meatal regression after hypospadias repair.

OBJECTIVE: To evaluate the efficacy of MAGPI's procedure in children who had a meatal regression after hypospadias repair. PATIENTS AND METHODS: Twenty-one children affected by post-hypospadias repair meatal regression underwent a modified MAGPI repair between January 1992 and January 1999: the patients, aged between 3 and 12 years (mean 5.9), had previously undergone hypospadias repair according to the techniques of Duplay (11 patients), Mathieu (2 patients), Snodgrass (5 patients) or the onlay buccal mucosa graft (3 patients). The outcome of the procedure was evaluated in terms of urinary stream and cosmetic appearance. RESULTS: The results were good in 18 patients, fair in 2, unchanged in 1. CONCLUSIONS: MAGPI's repair has proven to be very effective as a secondary procedure in meatal regression after hypospadias correction, with minimal morbidity and a highly successful outcome in terms of satisfactory functionality and cosmetic appearance, and the recovery of gaps as large as 9 mm.     

Analysis of meatal location in 1,244 healthy men Definition of the normal site justifies the need for meatal advancement in pediatric anterior hypospadias cases

The normal site of the external urethral meatus on the glans penis and the need for meatal advancement in patients with anterior hypospadias was studied. The location of the external meatus was analyzed in 1,244 men (mean age 28 years) with classification of the meatal position in relation to the tip of the glans and corona. The quality of erections and sexual intercourse, the presence of a penile curvature, urinary stream, and ability to void in a standing position were assessed in an interview. In 1,198 men (96.3%) the meatus was located on the distal third of the glans, in 43 (3.5%) on the middle third, (B), and in 3 (0.2%) on the posterior third. In no case was it located below the corona. One of the 3 men with the meatus on the posterior third had an associated mild penile curvature that did not cause difficulty in sexual intercourse. This study suggests that the normal site of the external meatus is at the tip of the glans. The definition of the normal site and the percentage of men with a normal meatal position justifies the need for meatal advancement in patients with anterior hypospadias when the goals of current hypospadias surgery are considered. Accepted: 17 June 1998     

New concept in urethral advancement for anterior hypospadias

ObjectiveWe report on our experience with urethral mobilization and advancement as a treatment for anterior hypospadias.Patients and methodsFrom January 2004 to March 2007, 55 out of 160 children with anterior hypospadias were managed by urethral mobilization and advancement; 46 had a mean follow-up period of 25 months (range 6–38) and are the subjects of this report. Their ages ranged from 2.5 to 12 years with mean age 4.5 years. The dissection began proximally in the avascular plane above the tunica albuginea covering each corpus cavernosum medially until reaching beneath the corpus spongiosum up to the hypospadiac meatus. Tension-free urethral anastomosis was achieved. The ventral glans was incised deeply at the interballanitic groove. The two glans wings and ventral glanular mucosal flaps were mobilized laterally. Interrupted sutures were placed through the tunica albuginea of corpus spongiosum to the corpora cavernosa. The mobilized urethra was wrapped by dartos fascia. The urethral stent was removed 24 h postoperatively.ResultsThree-fold urethral mobilization was sufficient to achieve tension-free urethral anastomosis. A slit-like orthotopic meatus, with conically shaped glans and straight penis, was achieved in all but one subcoronal case with mid-glans meatal retraction during our early experience. Postoperative urethral fistula was not recorded in any patient. Satisfactory urinary stream for parents and child was reported in 42/46. Peak flow rate was within normal range (upper 50% percentile) in all.ConclusionUrethral mobilization should begin proximally. Three-fold penile urethral mobilization, deep interballanitic incision and wide dissection of the glans can provide a slit-like orthotopic meatus with conical glans and straight penis in cases of anterior hypospadias without hypoplastic distal urethra and persistent ventral curvature after penile skin degloving, regardless of the presence of unhealthy, narrow urethral plate, shallow glanular groove, and flat or small glans.     

Snodgrass和Onlay术式治疗尿道下裂的疗效评价

目的评价和比较Snodgrass和Onlay两种术式治疗尿道下裂的临床疗效。方法对2006年11月至2012年7月施行Snodgrass和Onlay手术的140例尿道下裂患儿的临床资料进行回顾性分析。结果Snodgrass组治愈率为73．7％,尿道瘘发生率为18．4％,尿道狭窄发生率为11．8％;Onlay组治愈率为93．8％,尿道瘘发生率为6．3％,尿道狭窄发生率为1．6％。两组比较,治愈率Onlay组显著高于Snodgrass组,P〈0．05;尿道瘘及尿道狭窄发生率Onlay组显著低于Snodgrass组,P〈0．05。结论对背侧包皮丰富,尿道板发育良好,且不伴严重下弯的尿道下裂患儿,Onlay术式疗效优于Snodgrass术式。     

尿道板纵切卷管尿道成形术治疗尿道下裂22例

目的 探讨尿道板纵切卷管尿道成形术（Snodgrass法）手术治疗尿道下裂的适应证、手术技巧、并发症。方法 2005年9月～2006年11月本院应用Snodgrass手术治疗尿道下裂22例。年龄2～18岁。首次手术16例，采用尿道板正中切开卷管。再次手术6例，采用残余尿道板或阴茎皮肤正中切开卷管。卷管长度1～10cm。新尿道采用F6或飚号的硅胶气囊尿管作为支架管，术后10～14d拔除。结果 22例中18例一次手术成功，阴茎伸直良好，外形美观，排尿正常，成功率81．8％（18／22）。尿瘘3例，均已行尿瘘修补术痊愈。尿瘘并尿道狭窄1例，尿道扩张后狭窄改善，尿瘘待手术。结论 Snodgrass手术操作相对简单，手术者容易掌握，术后外形美观，并发症少。     

Long-term follow-up of children who underwent severe hypospadias repair using an online survey with validated questionnaires

ObjectiveFew studies of hypospadias repair in childhood have used validated questionnaires to investigate outcomes of cosmesis, urinary function, and sexual function in adulthood. We sought to investigate long-term outcomes in adult patients who had undergone severe hypospadias repair as children using an existing web-based application available to multiple institutions in order to develop an online patient survey of previously validated questionnaires.Materials and methodsPatients aged 18 years or older who underwent severe hypospadias repair between 1992 and 1997 at our institution were contacted to complete an online survey. Through medical chart reviews, we analyzed the location of meatus, type of repair, and complications. The online survey included questions about penile appearance, and validated questionnaires to assess urinary and sexual function.ResultsOf 58 patients who met the inclusion criteria, we contacted 19, and 13 completed the survey. Fifty-nine percent had complications, with an average of 2.2 procedures per patient. Most (85.0%) were satisfied with penile appearance, although 38.0% had residual penile curvature. Hypospadias patients had mean lower orgasmic function than normal controls. Mean scores for urinary function and other domains of sexual function were similar to normal controls.ConclusionsAlthough the majority of adult patients were satisfied with the outcomes of penile appearance, urinary function, and sexual function, our online survey suggests decreased lower orgasmic function as measured by validated questionnaire. An online survey accessible to multiple institutions with validated questionnaires may facilitate assessment of long-term hypospadias results.     

Is it possible to create a slit-like meatus without incising the urethral plate?

A series of hypospadias repairs using the Mathieu and V-incision-sutured (MAVIS) technique, aiming to achieve a normal-looking,vertical, slit-like meatus in 32 patients was reviewed. A Mathieu procedure was performed in 26 patients as a primary repair and in 3 as a rescue operation. In another 3 patients who had severe proximal hypospadias with failed repair, techniques other than Mathieu's were used. Good cosmetic and functional results were achieved in all patients.There were no complications such as fistula or stricture formation. The MAVIS meatoplasty creates a natural-looking, slit-like glanular meatus in both distal and proximal hypospadias, even in complicated cases.     

The cutaneous advancement procedure for megameatus and intact prepuce repair

Megameatus and intact prepuce (MIP) is an unusual, anterior hypospadias variant characterized by a widely splayed coronal or subcoronal meatus, deep glanular groove, and normally conformed prepuce. This last finding can explain possible late recognition of the malformation. The MIP variant is not amenable to conventional repairs, and in recent years new types of repairs have been successfully developed. The author reports the results of a cutaneous advancement procedure (CAP) in 34 consecutive patients with the MIP variant of hypospadias. The procedure was successful in all patients with good cosmetic and functional results and without any discomfort during erection and intercourse. The CAP is a very simple and effective technique. It can also be done as an outpatient procedure and, in the author's experience, is particularly reliable for this unusual hypospadias variant.     

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。     

Snodgrass手术在治疗失败尿道下裂中的应用

目的探讨尿道板纵切卷管尿道成形术(Snodgrass法)对治疗失败尿道下裂的临床疗效。方法回顾性分析广州军区总医院泌尿外科2002年3月-2011年4月接受Snodgrass法治疗的81例阴茎皮肤少的治疗失败尿道下裂患者的临床资料,并与36例同期应用Duplay尿道成形术修复的阴茎皮肤相对充裕的治疗失败尿道下裂患者进行比较。2种治疗方法均留置尿道U形支架管,U形支架管两端分别从会阴部尿道及尿道外口引出,均采用肉膜瓣覆盖成形尿道。结果随访6个月～2 a,应用Snodgrass手术治疗81例,成功65例(80.2%),术后并尿道瘘11例,尿道狭窄5例。Duplay尿道成形术治疗36例,成功29例(80.6%),术后并尿道瘘5例,尿道狭窄2例。2组手术成功率比较差异无统计学意义(P>0.05)。结论 Snodgrass手术用于儿童阴茎皮肤少的治疗失败尿道下裂的修复,可取得满意效果。     

The importance of patient selection in the treatment of distal hypospadias using modified Koff procedure

ObjectiveWe present our experience in the treatment of distal hypospadias using a modified Koff procedure, emphasizing the importance of patient selection for a good outcome.Materials and methodsIn 2003–2008, 90 patients, mean age 52.1 months, underwent surgical repair of distal hypospadias using urethral advancement according to Koff, modified with a Ψ incision on the tip of the glans. Meatal defect was glanular in six (8%), subglanular in 24 (26%) and coronal in 60 (66%) cases. Mild chordee was present in 19 patients (21%). Follow-up was 8–66 months. All patients were evaluated in terms of cosmetic results, and early and late postoperative complications.ResultsAll patients showed excellent cosmetic results with urethral meatus on the tip. There was only one postoperative fistula due to extensive use of electrocautery during urethral mobilization that was surgically corrected 8 months after appearance. One patient had a postoperative meatal stenosis treated conservatively. No cases of residual chordee were detected.ConclusionsSuccessful use of the modified Koff procedure depends on careful selection of patients. Good candidates are those with distal or mid-shaft hypospadias, presenting with: (1) absence or low degree of ventral chordee; (2) distal plate of urethra well developed; (3) distance between meatus and tip of glans at most 10–12 mm; and (4) glanular morphology preserved.     

Factors affecting outcome of one-stage anterior hypospadias repair: analysis of 422 cases

The repair of hypospadias is among the most difficult problems in urology, as it demands the construction of a well-functioning urethra and a good cosmetic appearance. We performed a retrospective analysis of 422 cases subjected to one-stage anterior hypospadias repair between 1982 and 1999 in our clinic and investigated the effects of factors like degree of hypospadias, surgical technique, and the surgeon's experience on outcome. The operations used were MAGPI (91), urethral advancement (10), Mathieu (260), modified Allen-Spence (50), onlay island flap (5), and double-faced island flap (6) procedures. The early complication rate was 18%, while the final success rate following secondary interventions was 95%. The complications included fistula formation in 49 cases (12%), flap necrosis in 12 (3%), meatal problems in 12 (3%), residual chordee in 4 (1%), and urethral stricture in 1 (<1%). Complication rates were significantly higher if the meatus was proximal or there was severe chordee and in the first 6 years of the study. The flap procedures were associated with a higher complication rate. It is concluded that one-stage procedures are successful in the repair of anterior hypospadias in experienced hands with proper patient selection. Accepted: 21 March 2001     

Is objective assessment of cosmetic results after distal hypospadias repair superior to subjective assessment?

ObjectiveTo evaluate whether systematic scoring of pictures is really superior to subjective evaluation in the assessment of cosmetic results of distal hypospadias surgery, and whether any differences exist in subjective evaluation among the operating surgeon, the parents of the child, and a third party not previously involved in the care of the patient.Patients and methodsTwenty-seven patients undergoing distal hypospadias repair by either the Snodgrass or Mathieu technique were enrolled. Cosmetic results of surgery were scored from 0 to 10 by one of each child's parents and by three surgeons. The latter assessed the results blindly on pictures taken during the outpatient visits; one used a systematic scoring system while the other two including the operating surgeon used subjective scoring. The four scores were compared using the Kendall W coefficient of concordance.ResultsOverall, there was excellent concordance among the four observers (P < 0.0001). The Snodgrass repair allowed for significantly better cosmetic results overall.ConclusionIn distal hypospadias, subjective evaluation of overall penile appearance can be as reliable as an evaluation made using a systematic scoring system. There seems to be excellent concordance among the subjective evaluations of different observers.