阴茎修复和功能重建(附62例报道)

目的:探讨严重阴茎病变(畸形)的外科治疗方法。方法:62例患者年龄19～63岁(平均35岁),其中阴茎部分缺失4例,分别行阴茎缺损修复、阴茎延长术、尿道成形术;阴茎完全缺失3例,行阴茎再造术;阴茎严重弯曲22例,行"16点"弯曲矫正术;阴茎折断15例,1例保守治疗,14例分别修补阴茎海绵体、尿道海绵体,阴茎背深静脉结扎;假体植入术后并发症5例,包括假体从尿道穿出、水泵失灵、连接管断裂,勃起角度<60°和海绵体无法扩张,分别行假体取出、修补尿道裂口,更换新的假体,切除纤维化的瘢痕再次植入假体;阴茎完全离断4例,行阴茎再植术;撕脱伤3例,行皮瓣回植和游离植皮;阴茎Paget病6例,行病灶切除、游离植皮和阴茎埋入阴囊。结果:该组随访3个月至4年,平均9个月,4例阴茎部分缺失患者,2例术后阴茎外形满意,性功能恢复,较满意和不满意各1例。阴茎完全缺失3例术后外形满意,排尿好,1例不满意。22例阴茎严重弯曲均被矫正,1例复发。阴茎折断15例,失访1例,14例获得随访,性功能均恢复,术后并发症5例,分别为轻度弯曲、性交痛、皮下硬结、硬度差、性快感差,未作进一步处理。假体植入术后并发症5例,再次手术均成功,术后均能进行性生活,4例配偶满意,仅1例配偶不满意。阴茎完全离断4例,2例再植成功,2例坏死。撕脱伤3例植皮均获得成功。6例阴茎Paget病患者术后皮瓣均成活,随访2～4年,1例死于脑转移,5例无瘤存活至今。结论:该类病例需在泌尿男科手术的基础上,配合显微外科技术、皮瓣或皮肤移植技术等,设计个性化手术方案,能解决大多数患者的阴茎形态和勃起功能障碍,但部分患者仍不能达到理想的外形或功能,有待于寻求新的治疗方法。     

Correlation between the skull base fracture and the incidence of intracranial hemorrhage in patients with traumatic brain injury

Purpose: A head injury (HI) may cause a skull fracture, which may or may not be associated with injury to the brain. In essence, a skull base fracture (SBF) is a linear fracture at the base of the skull. Loss of consciousness and Glasgow coma score (GCS) may vary depending on an associated intracranial pa thology. The pathomechanism is believed to be caused by high energy impact directly to the mastoid and supraorbital bone or indirectly from the cranial vault. Aim of this study is to define the correlation be tween SBF and intracranial hemorrhage (ICH) in patients with HI. Methods: Analysis of data obtained from a retrospective review of medical records and from a system atized database pertaining to diagnostic criteria of SBF patients based only on clinical symptoms asso ciated with ICH caused by HI treated in the Department of Neurosurgery at Dr. Hasan Sadikin Hospital, Bandung, Indonesia from January 1, 2012 to December 31, 2017. The exclusion criteria included age less than 15 years and no head computed tomography (CT) scan examination provided. Results: A total of 9006 patients were included into this study in which they were divided into 3 groups: group 1, HI with no ICH; group 2, HI with single ICH and group 3, HI with multiple ICH. In all the SBF cases, SBF at anterior fossa accounted for 69.40% of them, which were mostly accompanied with mild HI (64.70%). Severity of HI and site of SBF correlated with the existence of traumatic brain lesions on CT scan, thus these factors were able to predict whether there were traumatic brain lesions or not. Most of the patients with epidural hemorrhage (EDH) has single traumatic lesion on CT scan, whereas most of the patients with cerebral contusion (CC) has multiple traumatic lesions on CT scan. On patients with both traumatic brain injury and SBF, most of the patients with anterior fossa SBF has EDH; whereas most of the patients with middle fossa SBF were accompanied with CC. Surgery was not required for most of the patients with SBF. Conclusion: SBFs were strongly correlated with traumatic ICH lesions patients with anterior fossa SBF were more likely to suffer EDH whereas with middle fossa SBF were more likely to suffer CC.     

Spontaneous CSF Leaks From the Temporal Bone

Spontaneous cerebrospinal fluid leaks from the temporal bone seem to be rare; however, increasing numbers of cases are being reported. This paper reports 14 cases. The presenting symptoms included hearing loss, external leaks, mass in the middle ear and external meatus, and facial paresis. All cases were evaluated with computed tomography (CT), eight with CT cisternography, and six with magnetic resonance imaging. In all patients the defect was found in the tegmen; in two, an additional defect could be detected in the posterior fossa. All were surgically treated by a transmastoid extradural technique. There are no recurrences after a mean follow-up period of 1.2 years (5 months to 2.4 years).     

Spontaneous CSF Leaks From the Temporal Bone

Spontaneous cerebrospinal fluid leaks from the temporal bone seem to be rare; however, increasing numbers of cases are being reported. This paper reports 14 cases. The presenting symptoms included hearing loss, external leaks, mass in the middle ear and external meatus, and facial paresis. All cases were evaluated with computed tomography (CT), eight with CT cisternography, and six with magnetic resonance imaging. In all patients the defect was found in the tegmen; in two, an additional defect could be detected in the posterior fossa. All were surgically treated by a transmastoid extradural technique. There are no recurrences after a mean follow-up period of 1.2 years (5 months to 2.4 years).     

Neurosurgical problems in craniofacial surgery for maxillofacial and ENT diseases]

From June 1978 to June 1990, 48 patients (34 patients with skull base tumors and 14 with congenital hyperterolism) were treated by combined craniofacial surgery. Cranial approaches were performed through the anterior fossa in 7 patients, middle fossa in 19, posterior fossa in 1, both anterior and middle fossa in 6, middle and posterior fossae in 1 and bilateral anterior fossae in 14. Neurosurgical problems were discussed.     

鼻内镜联合显微镜经鼻腔蝶窦及中颅窝手术

目的探讨鼻内镜下经鼻腔直接入路行蝶窦及中颅窝手术的方法. 方法鼻内镜下经较宽大一侧鼻腔将中鼻甲向外推移,鼻腔扩张器扩大视野,直达并开放蝶窦前壁, 鼻内镜与显微镜联合切除病变. 结果 10例孤立性蝶窦炎术后症状消失.6例蝶窦囊肿、脑膜瘤均一次手术切除.32例垂体腺瘤17例全切除,12例次全切除,3例大部分切除,术后补充X刀治疗.48例术后随访6个月～3.5年,平均2.5年,蝶窦囊肿、蝶窦炎、脑膜瘤无复发,3例垂体腺瘤复发,无颅内感染并发症,无鼻腔粘连、鼻出血等鼻腔并发症. 结论鼻内镜联合显微镜经鼻腔蝶窦及中颅窝手术损伤小、出血少、手术时间短、效果好.     

Traumatic extradural haematomas in children: Experience with 62 cases

Summary Sixty-two children with traumatic extradural haematomas are considered. According to the clinical history presented—often atypical— and to the grade of neurological impairment, patients have been divided into different clinical groups. Nearly 50% of patients sustained a minor injury, and 26% did not lose consciousness after trauma. Twenty-four per cent of patients did not show fractures on skull X-rays. Atypical location of the haematoma was noted in 22 cases, mainly in the anterior fossa (19 cases).Sixty patients were operated on, while two patients were conservatively treated, owing to the limited size of the haematomas and to the absence of neurological deficits. Associated brain lesions were discovered at surgery in 40% of cases.The overall mortality rate has been 17%, the operative mortality rate 14%. The morbidity rate has been 6%, with 3% of patients presenting severe disability. Morbidity and mortality have been shown to be affected by age—with better prognosis in patients under 10 years of age, by the clinical history presented, by the preoperative conditions, and, mainly, by the presence of associated brain lesions. As regards location, frontal haematomas have shown a better prognosis and a slower course than convexity haematomas. Finally, prognosis of extradural haematomas in children has improved to some extent in the last years with the advent of the CT scan, possibly due to speed and accuracy of diagnosis.     

Trigeminal neurinomas extending into multiple fossae: surgical methods and review of the literature.

OBJECT: Since 1974, 27 patients with trigeminal neurinomas (TNs) have been treated at Keio University Hospital and ancillary institutes. In the present study the clinical features and developmental patterns of these 27 cases are analyzed, and the clinical features of 402 cases reported in the literature are reviewed. Based on the analysis of the developmental patterns of the TNs, the surgical strategy for a one-stage removal of TNs involving multiple fossae is described. METHODS: Trigeminal neurinomas are classified into six types according to tumor location. Types M, P, and E are tumors involving a single compartment, that is, the middle fossa, posterior fossa, or extracranial space, respectively. Types MP (middle and posterior fossae), ME (middle fossa and extracranial space), or MPE (middle and posterior fossae and extracranial space) are tumors involving multiple compartments. Advances in neuroimaging technologies, such as magnetic resonance imaging, have revealed a high incidence of TNs extending into multiple fossae, namely 36.2% in cases reported since 1983 and 59% in the authors' series. All but one of the most recent 19 patients in this series underwent skull base surgery, whereas the remaining nine patients were surgically treated via the conventional subdural approach. The rate of total tumor removal and the clinical outcome were significantly better in those patients treated by skull base surgery than those treated by conventional surgery. CONCLUSIONS: The TNs extending into multiple fossae can be totally removed using the following single-stage surgical techniques: Type MP by the anterior transpetrosal approach; Type ME by the zygomatic or orbitozygomatic infratemporal approach; and Type MPE by the zygomatic transpetrosal approach. In 12 of 13 cases involving multiple fossae in this series, total tumor removal was achieved using single-stage skull base surgery.     

Notice

Thirty-one cases of arachnoid cysts of the middle cranial fossa were investigated by CT scan, 7 of them undergoing additional metrizamide CT cisternography. In this paper we analyze and correlate the different findings from these two examinations and propose a classification of arachnoid cysts of the middle cranial fossa into three basic types. Pathophysiological and surgical implications are discussed.     

Scapular body fractures: results of operative treatment

The authors operated on 22 patients with scapular body fractures, with a mean age of 35 years. The minimal follow-up was 12 months. All patients were treated from the Judet posterior approach. The study included 14 cases of an isolated body fracture, three of scapular body fracture combined with fracture of the scapular neck and five of glenoid fossa fracture. In all 14 cases where a 3D computed tomography (CT) reconstruction was performed prior to operation, intraoperative findings corresponded to this reconstruction. In eight cases without preoperative 3D CT reconstruction, the correct type of fracture was identified in only two cases. We also identified three basic types of fractures of the lateral border of the scapula. The anatomical relationship between the glenoid fossa and scapular body, congruency and stability of the shoulder joint was achieved in all cases. The average constant score was 94.     

Management of facial paralysis resulting from temporal bone fractures: Our experience in 115 cases.

OBJECTIVE: The goal of this study was to review decision factors and overall results regarding surgical and nonsurgical management of post-traumatic facial nerve paralysis (FP). STUDY DESIGN: A retrospective study and literature review were performed. METHODS: Between 1984 and 1990, 115 cases of post-traumatic FP were handled. Patients were evaluated through clinical, audiologic, radiologic, and electromyogram assessment. Depending on examination results, patients were treated either medically or surgically through total facial nerve decompression. RESULTS: Forty-nine of the 50 medically treated patients experienced a normal or subnormal facial function recovery (grade I-II). Of the 65 (56.5%) surgically treated patients, 52 (80%) had immediate, 2 had delayed, and 11 (17%) had unknown delay-associated FP. The approaches chosen were middle fossa and transmastoid (75.3%), translabyrinthine (10.7%), or pure transmastoid according to facial nerve nonmotor branch evaluation, hearing, location of the fracture line, and the patient's general condition. Lesions were predominantly found in the geniculate ganglion area (66.2%). A nerve gap was found in only 13.8% of the cases. At 2 years after surgery, 93.8% had a grade I to III recovery. None had grade V or VI. CONCLUSION: The rarity of severe nerve lesions encountered in surgically treated patients raises the question of better selection of candidates for surgery. Surgery is clearly indicated when FP is total, is of immediate onset, and is associated with a bad prognosis electromyogram pattern. In other settings, decisions are to be made based on high-resolution CT data and electromyogram results, thanks to a clinical survey and second electromyogram evaluation.     

Brain stem glioma: the role of a biopsy

A retrospective review of the clinical and histopathological features of 31 patients with brain stem gliomas treated between 1965 and 1990 at Kyushu University Hospital was performed to determine the role of biopsy on these lesions. These 16 male and 15 female patients ranged in age from 3 to 50 years at diagnosis (average: 18.1 years). The primary site of the tumour was the pons in 20 patients, followed by the medulla oblongata and midbrain, and the final histological diagnoses of the lesions based on either the biopsy or autopsy materials were grade I astrocytomas in five patients, grade II in nine, grade III in 10, grade IV in five, and ependymoma in two patients. No consistent correlation could be obtained between the CT findings and histological diagnoses. Open surgical posterior fossa exploration was performed on 17 patients (diagnostic biopsy: 10; volume reduction by tumour removal with or without cyst evacuation: 7) and stereotaxic biopsy on three patients, without any mortality related to these procedures. In our biopsy series, half of the patients with grade II astrocytoma died within 12 months after diagnosis, whereas three out of four patients with grade I astrocytoma survived more than 10 years after diagnosis. Because of the relative safety of the tissue sampling technique, and the importance of an accurate diagnosis in order to select appropriate treatment modalities, histological verification of the lesion should be considered for all patients harbouring a brain stem mass lesion.     

Acoustic intrameatal meningiomas

BACKGROUND: The sporadic finding of an acoustic intrameatal meningioma stimulated the authors to the present study. An analysis of the cases previously reported in the literature aimed to outline a preliminary account about biological, radiological and surgical specific hallmarks of these tumours. METHODS: Eight previous cases of meningiomas, meeting the prerequisite of origin and situation within the internal acoustic canal, have been discovered in the known literature since 1975. A further case was recently observed in our experience. The cases in the series showed no sex prevalence and in most of them the age of incidence was comprised between the fifth and sixth decade of life. Hearing loss was the prevalent symptom, lasting 1 month to 7 years before presentation. Myelocisternography, myelo-CT or high resolution CT/MR revealed no specific radiological features to distinguish small intrameatal meningiomas from the more frequently occurring vestibular schwannomas, while CT scan with bone algorithm could point out valuable indirect details for differential diagnosis. Various surgical approaches, i.e. middle fossa, translabyrinthine and retromastoid, were utilized by the different authors. RESULTS: Basing on apparent individual surgical preference, one of three different surgical routes (translabyrinthine, middle fossa, retromastoid) was chosen for 10 procedures in 9 patients. In all, except two cases the impression at surgery was of complete tumour removal. CONCLUSIONS: The possibility for meningiomas to recur and invade the surrounding bone requires a differential diagnosis from vestibular schwannomas. In the absence of intrinsic distinctive signs, radiological evaluation of peritumoral bone alterations could help diagnosis. Although the various surgical routes have often proved effective, temporal bone invasion justifies more extensive approach even in small tumours.     

Vascularized temporalis muscle flap for the treatment of otorrhea. Technical note

The surgical treatment for cerebral spinal fluid (CSF) fistulas provides closure of the bone and dural defects and prevents the recurrence of brain herniation and CSF fistula. The two main approaches used are the transmastoid and middle fossa ones. The authors review the results of performing a modified middle fossa approach with a vascularized temporalis muscle flap to create a barrier between the repaired dural and bone defects. Fifteen consecutive cases of CSF fistulas treated at the authors' institution were retrospectively reviewed. All patients presented with otorrhea. Eleven patients had previously undergone ear surgery. A middle fossa approach was followed in all cases. The authors used a thin but watertight and vascularly preserved temporalis muscle flap that had been dissected from the medial side of the temporalis muscle and was laid intracranially on the floor of the middle fossa, between the repaired dura mater and petrous bone. The median follow-up period was 2.5 years. None of the patients experienced recurrence of otorrhea or meningitis. There was no complication related to the intracranial temporalis muscle flap (for example, seizures or increased intracranial pressure caused by muscle swelling). One patient developed hydrocephalus, which resolved after the placement of a ventriculoperitoneal shunt 2 months later. The thin, vascularized muscle flap created an excellent barrier against the recurrence of CSF fistulas and also avoided the risk of increased intracranial pressure caused by muscle swelling. This technique is particularly useful in refractory cases.     

Management strategies for anterior cranial fossa (ethmoidal) dural arteriovenous fistulas with an emphasis on endovascular treatment

OBJECT: Dural arteriovenous fistulas (DAVFs) of the anterior cranial fossa are rare lesions that can cause intracranial hemorrhage. Authors of previous reports mostly have described open surgical treatment for this fistula type. The authors' purpose in the present study was to describe their experience with anterior cranial fossa DAVFs, including their endovascular treatment. METHODS: All patients with anterior cranial fossa DAVFs diagnosed and treated in 3 separate institutions during the last 23 years were retrospectively identified. Clinical charts, imaging studies, and procedural notes were evaluated. RESULTS: Twenty-four patients (22 males and 2 females), ranging in age from 3 to 77 years, harbored 24 DAVFs in the anterior cranial fossa. Eleven patients were primarily treated with surgical disconnection and 2 with radiosurgery. Eleven patients were treated endovascularly; 7 of these patients (63.6%) were cured. In 4 cases of failed embolization, final disconnection was achieved through surgery. In fact, surgery was effective in disconnecting the fistula in 100% of cases. All endovascular procedures consisted of transarterial injections of diluted glue (N-butyl cyanoacrylate [NBCA]), and there were no complications. Brain edema developed around the venous pouch and confusion was apparent after venous disconnection in 1 surgically treated patient. No patient suffered a hemorrhage during the follow-up period. CONCLUSIONS: Disconnection of an anterior cranial fossa DAVF by using transarterial catheterization through the ophthalmic artery and subsequent injection of NBCA is possible with a reasonable success rate and low risk for complications. In patients with good vascular access this procedure could be the treatment of choice, to be followed by open surgery in cases of embolization failure.     

扩大中颅窝硬膜外手术入路的研究与应用

目的　介绍扩大中颅窝硬膜外手术入路。　方法　经扩大中颅窝硬膜外手术入路治疗颅底肿瘤２０ 例。　结果　肿瘤全切除１６ 例，次全切除３ 例，大部切除１ 例，无手术死亡。随访２ 个月～２ 年，未见肿瘤复发。　结论　中颅底硬膜外、海绵窦及中、后颅底哑铃型肿瘤可经扩大中颅底硬膜外入路进行手术     

Cholesterol Granuloma in the Petrous Apex: Case Report and Review

Summery. Cholesterol granuloma in the petrous apex presents with various symptoms of cranial nerve dysfunction, so the selection for surgical treatment remains controversial. We report a 41-year-old woman with a cholesterol granuloma at the left petrous apex, which was totally resected via a combined middle fossa and posterior transpetrosal approach. In a review of 92 cases, including our case, treated for petrous apex cholesterol granuloma between 1990 and 2001, 38 were men (41.3%) and 54 were women (58.7%). The mean age of these patients was 37.4 years (males were 35.2 years, females were 39.4 years). The most common presenting clinical symptom was hearing loss due to dysfunction of cranial nerve VIII. Seventy-nine patients, including our case, underwent operation, and 13 patients were managed without surgery. The most frequently selected surgical approach was middle cranial fossa approach. Revision surgery (including the 2 cases who underwent revision twice and three times) was performed in 12 patients (15.2%). In 92 cases, all of those who underwent total removal have not shown re-accumulation of cyst contents. On the other hand, 11.4% of the patients with or without permanent drainage route proceeded by subtotal removal of the cyst wall needed revision surgery because of stenosis of the drainage route. Therefore we conclude that the most important treatment for the prevention of re-accumulation of cyst contents may be the extent of the cyst wall resection rather than the establishment of permanent drainage route.     

Endoscopic Endonasal Approach to the Middle Cranial Fossa through the Cavernous Sinus Triangles: Anatomical Considerations

The lateral limit of endoscopic endonasal surgery has yet to be defined. The aim of this study was to investigate the lateral limit of endoscopic endonasal surgery at the level of the sphenoid sinus. Access from the sphenoid sinus to the middle cranial fossa through the cavernous sinus triangles was evaluated by cadaver dissection. Anatomical analysis demonstrated that the medial temporal dura mater was exposed through the anterior area of the clinoidal triangle, anteromedial triangle, and superior area of the anterolateral triangle, indicating potential corridors to the middle cranial fossa. This study suggests that the cavernous sinus triangles are applicable in selected cases to manage middle cranial fossa lesions by endoscopic endonasal surgery.     

Acoustic neuromas and serviceable hearing: choosing the surgical approach

The principal objectives of acoustic neuroma surgery in the order of priority are absence of mortality and neurological morbidity, total removal of the lesion, preservation of facial function, and preservation of hearing. The aim of this work was to evaluate the selection criteria and the therapeutic strategy for hearing preservation in acoustic neuroma management. This retrospective study included 436 consecutive patients referred to our department for an acoustic neuroma. The population comprised 365 patients (84%) treated surgically, 66 patients (15%) managed conservatively, and 5 irradiated patients (1%). The mean age was 54 years (range: 13-87). The mean follow-up period was 24 months (range: 1-120). The surgical approaches were translabyrinthine in 294 (81%), retrosigmoid in 37 (10%), and through the middle fossa in 34 cases (9%). Approaches preserving the labyrinth were employed in patients aged less than 60 years with lesions measuring or=50%). A serviceable hearing was preserved in 53% of the cases with a serviceable hearing in 44% of the cases. Postoperative normal or subnormal facial function was obtained in 72 to 98% of cases depending on tumor size. Two cases (0.5%) of recurrence were reported. In conclusion, our surgical strategy based on age, tumor size and pre-operative hearing function permitted hearing preservation in 50% of selected cases, a high rate of facial function preservation and a low risk of recurrence.     

Ganglioglioma of the brainstem: report of three cases and review of the literature.

BACKGROUND: Brainstem gangliogliomas are rare low-grade tumors that usually have a long clinical history. However, they may cause sudden death. There are only 31 cases of brainstem ganglioglioma reported in the literature, and only one has been studied with magnetic resonance (MR). We present three new cases of brainstem ganglion cell tumor studied with computed tomography (CT) (3 cases) and MR (2 cases) and discuss the clinical presentation, diagnostic imaging and treatment of these tumors. CASE DESCRIPTION: Age at presentation ranged from 19 to 59 years old. Two patients were female and 1 male. Duration of symptoms before diagnosis ranged from 1 year to nearly 14 years. Presenting complaints included syncope spells, cranial nerve deficits, headache, and gait instability. Imaging studies revealed well-circumscribed lesions involving the brainstem; the lesion was cystic in one case and calcified in one. They were iso- or hyperdense on CT scan, isodense on T1-weighted and hyperdense on T2-weighted MRI and frequently showed contrast enhancement.All tumors were operated through a posterior fossa craniectomy. Using microsurgical techniques only partial resection could be achieved, as there was no sharp delineation from the surrounding tissue in any case. Two of our patients had increased neurological deficits after surgery. Radiotherapy was not given. Follow-up of tumoral remnants has not shown clear tumor growth after 1, 3.5, and 10 years. CONCLUSIONS: Imaging characteristics of brainstem gangliogliomas do not seem to differ from those in other locations and are not specific. Radical surgery is rarely if ever possible, nor is it advisable because of the risk of functional deterioration. However, because of their benign histology, partial resection seems to carry a similar prognosis as tumors in other locations that are amenable to complete resection.