预置尿道的阴茎再造术尿道口吻接的技术改进

目的:探讨一种以双蒂皮瓣加强覆盖尿道吻合口以降低再造阴茎尿瘘发生率的方法。方法:女复男性别重赋手术患者,在掀起预置尿道的皮瓣形成阴茎体时,尿道口近端保留2cm皮肤,一期尿道旷置。二期尿道吻接时将此皮肤掀起形成双蒂皮瓣,覆盖在尿道吻接口上。结果:3例患者吻合口均一期愈合,排尿通畅,无尿瘘及狭窄发生。结论:预置尿道的阴茎再造术尿道口吻接采用本技术改进可以较好地避免尿瘘或狭窄问题的出现。     

阴茎再造术后尿道狭窄的护理

阴茎再造术后尿道狭窄是女变男易性病患者阴茎再造术后常见并发症之一。我科自1998～2012年以来收治女变男易性病患者阴茎再造280多例,有10例患者在阴茎再造术后半年或数年后出现了尿道狭窄,症状为排尿困难、尿线极细。     

阴茎再造术后皮瓣血运障碍8例的护理

阴茎再造术是易性病女复男患者标志性手术。我科自2010年1月～2012年6月采用双侧阴股沟皮瓣为62例易性病女复男患者施行阴茎再造术,其中有8例患者术后出现皮瓣血运障碍,术后经过仔细地观察、及时的处理和精心的护理,使再造阴茎皮瓣得到最大程度的成活,现将护理体会报道如下。     

阴茎再造术后尿瘘原因分析与治疗

女转男变形术中,阴茎再造的一个主要目标是站立排尿的能力,尿瘘是其术后的主要并发症之一。针对病因进行预防是降低阴茎再造术后尿瘘的根本所在。同时,随着医学及相关学科的进步,组织工程等新技术有望用于修复术后尿瘘。本文对阴茎再造术后尿瘘的原因与治疗方法进行综述。     

尿道口周蒂肉膜瓣在阴茎中段型尿道下裂一期修复中的应用

目的探讨采用横形包皮岛状皮瓣管状尿道成形术一期修复阴茎中段型尿道下裂的方法及临床效果。方法对自2010年1月至2014年12月收治的46例男性先天性阴茎中段型尿道下裂患者,行阴茎矫直、横形包皮岛状皮瓣管状尿道法一期尿道再造术。术中保护尿道口近端区域的肉膜组织,形成尿道口周蒂肉膜瓣;翻转肉膜瓣、覆盖尿道吻合口并固定,将皮瓣转移覆盖至阴茎腹侧的皮肤缺损。结果所有患者术后随访5~36个月,仅发现1例吻合口尿道瘘,1例阴茎腹侧部分皮肤血运欠佳而致切口瘢痕愈合,但无尿瘘发生,其余患者均愈合良好,无尿道裂开、皮瓣坏死、感染、尿道(口)狭窄、尿道憩室等并发症发生。结论采用横形包皮岛状皮瓣管状尿道成形术一期尿道再造治疗阴茎中段型尿道下裂,并采用尿道口周蒂肉膜瓣覆盖吻合口,是一种简单且可有效预防其吻合口尿瘘发生的较好方法。     

“旗形”胸脐皮瓣结合自体肋软骨支架在阴茎再造术中的应用

目的:探讨利用"旗形"胸脐皮瓣结合自体肋软骨支架行阴茎再造的临床效果。方法:以腹壁下动脉为蒂设计脐旁皮瓣,皮瓣形态呈旗状,"旗杆"部为皮瓣血管蒂,"旗面"部用于阴茎成形及尿道成形。以"旗杆"为轴旋转180°转移至会阴部,将皮瓣翻转卷成管状形成尿道及阴茎体,并与会阴部尿道口吻合。手术同期切取自体肋软骨,雕刻为支撑材料置入阴茎体。术后半年可行二期手术修整阴茎形态,包括皮瓣去脂修薄、瘢痕切除等。结果:2010年8月-2016年8月供实施8例,术后皮瓣血运均良好,皮瓣供区均可于术中直接缝合关闭创面,伤口一期愈合。术后随访5～14个月,其中2例患者阴茎臃肿,于阴茎再造术后1年行皮瓣去脂修薄改善阴茎外形,满足性生活;2例术后3个月因尿瘘再次行手术修补;其余4例患者再造阴茎外观及功能均良好。所有患者均未见软骨外露,除脐部位置稍向皮瓣供区侧偏移,腹壁外形轮廓基本正常。结论:"旗形"胸脐皮瓣阴茎再造设计简单,术后效果较为理想,避免了传统胸脐皮瓣阴茎再造需要植皮覆盖创面的问题,减轻了腹壁继发畸形的发生,是一种可供选择及推广的阴茎再造术式。     

阴道黏膜瓣在女复男易性病尿道延长术中的应用

目的:探讨阴道黏膜瓣行尿道延长术在女复男易性病手术中的应用。方法:对37例女复男易性病患者采用阴道黏膜瓣行尿道延长术。结果:全部患者尿道延长手术均获成功,尿道口由原来的女性尿道口延长至耻骨联合,4例发生阴道黏膜瓣远端与皮肤缝合处黏膜糜烂,二期愈合。2例发生尿瘘,二期清创缝合后痊愈。结论:在女复男易性病患者的治疗中,利用发育较好的阴道黏膜施行尿道延长术,不仅使术后切口张力减小,而且减少术后尿道毛发生长导致毛石症的困扰。     

应用腹膜管联合皮瓣行兔阴茎再造的初步研究

目的：建立皮瓣包绕游离腹膜管再造阴茎的动物模型，探索在阴茎再造术中使用腹膜再造尿道的新方法。方法：成年雄性新西兰大白兔24只，随机分成腹膜组和腹膜皮片组各12只。再造阴茎时，腹膜组中将腹膜浆膜面向内缝合成腹膜管替代尿道，腹膜皮片组则在腹膜管前端吻接一段1cm长的阴囊皮片，形成腹膜皮片复合管，并以此管替代尿道，两组均以腹壁浅血管筋膜蒂皮瓣包绕再造尿道形成阴茎体，观察阴茎成活和尿道通畅情况。结果：再造阴茎全部成活，无尿道狭窄发生，作为尿道衬里的腹膜浆膜面光滑、湿润、富有光泽，未见溃疡及纤维化。腹膜组8只兔尿道口闭合，同时伴有尿瘘。腹膜皮片组3只兔各1处尿瘘。结论：使用皮瓣包绕游离腹膜管再造阴茎的方法可以成功构建阴茎再造的动物模型，为游离腹膜联合皮瓣转移阴茎再造术的临床应用提供了实验依据。     

易性病患者双侧阴股沟皮管延迟术后的护理

<正>皮瓣延迟术是女复男易性病患者手术中重要步骤之一,可直接影响阴茎再造术成功与否的关键,我科2011年1月~2013年12月为27例女复男易性病患者行双侧阴股沟皮管延迟术,其中一例皮下血肿,一例皮瓣血运障碍,术后通过精心护理使得皮管较大的存活,现将护理体会报道如下。1临床资料本组27例女复男易性病患者,年龄18~40岁。1.1手术方法:手术分两次进行,第一次为阴股沟皮     

尿道口蒂皮瓣与口腔黏膜联合一期修复尿道下裂

目的探讨尿道口蒂皮瓣与口腔黏膜对合重建尿道的方法.方法 2002年3月～2004年5月,采用尿道口蒂皮瓣与口腔黏膜联合重建尿道21例,年龄14个月～8岁.切断挛缩尿道板,彻底矫直阴茎后,将口腔黏膜移植于阴茎腹侧白膜,尿道口蒂皮瓣翻转后与口腔黏膜对合,形成管状尿道.结果术后所有患儿均获3～18个月随访,平均7个月.阴茎弯曲完全矫正,尿道外口位于阴茎头前端,阴茎外形良好,排尿通畅.2例发生尿瘘,其中1例自愈,1例术后6个月再修补成功.结论尿道口蒂皮瓣与口腔黏膜联合重建尿道能彻底矫正阴茎弯曲,提高手术成功率和改善术后阴茎外形.     

Prefabricated Anterolateral Thigh Flaps for Phalloplasty in Female-to-Male Transsexuals

Background Phalloplasty is still a challenging operation because of the high urethral complication rate.Several options regarding different flaps can be chosen,but there is still no perfect solution for phalloplasty in female-to-male(FTM)transgender patients.Our group tried to use prefabricated anterolateral thigh(ALT)flaps for phalloplasty to overcome the urethral complications.Methods A total of 21 transgender patients were included from 2010 to 2019.A twostage operation was performed to reconstruct the phallus.The vaginal mucosa was prefabricated as neourethra at the first stage,and the shaft of the phallus was reconstructed at the second stage.Results All reconstructed phallus survived completely in our study,and the satisfaction rate was 76.2%.The total complication rate was 57.1%.The occurrence of fistula and strictures after the operation was 52.4%and 5.8%,respectively Conclusion Prefabricated ALT flaps with vaginal mucosa have a lower stricture rate.This technique provides a simple,effective surgical option in FTM transsexuals.     

Ⅱ期原位皮瓣尿道成型治疗阴茎阴囊型尿道下裂26例体会

目的 探讨Ⅱ期原位皮瓣尿道成型术治疗阴茎阴囊型尿道下裂的临床疗效,提高先天性尿道下裂患者的手术治疗水平。方法 将2011年1月至2016年1月收治的26例阴茎阴囊型尿道下裂患者采取Ⅰ期阴茎伸直,包皮行阴茎腹侧皮瓣转移,6个月后行Ⅱ期原位皮瓣尿道成型术治疗尿道下裂。结果 26例患者中2例出现尿道狭窄,经规律尿道扩张后排尿症状改善;1例出现吻合口尿瘘,6个月后修补成功;所有病例均随访2~3年,排尿通畅,疗效满意。结论 原位皮瓣尿道成形,保证了成形尿道血供,降低了吻合口张力,具有损伤小,术后水肿轻,尿瘘、尿道狭窄发生率较低等优点,可有效提高手术疗效。     

兔阑尾黏膜预制尿道行阴茎再造的实验研究

目的 探讨以兔阑尾黏膜预制尿道行阴茎再造的可行性.方法 60只雄性新西兰兔随机分为两组,分别利用阑尾黏膜和皮片预制尿道,术后3个月行阴茎再造术.观察阑尾黏膜预制尿道后2周,1、2、3个月及阴茎再造术后1、3个月时尿道的组织学变化;对比两组阴茎再造术后1、3个月阴茎大体形态变化和逆行尿道造影改变;对比两组阴茎再造术后3个月时,尿道并发症发生率的差异.结果 阑尾黏膜预制尿道移植后,单层柱状上皮经历了早期脱落、再生,到后期逐渐萎缩凋亡,并被复层鳞状上皮逐渐移行、化生及取代的过程;阴茎再造术后 1个月,尿道已无单层柱状上皮存留,均被覆复层鳞状上皮,但上皮较薄,而再造术后3个月时,尿道复层鳞状上皮进一步增生增厚;两组再造阴茎大体形态无明显差异;逆行尿道造影显示,两组尿道早期吻合口处均存在管腔狭窄,逐渐趋于减轻;两组尿道狭窄及尿瘘并发症发生率差异具有统计学意义,阑尾黏膜组无尿路结石的发生,而皮片组由于毛发生长,6例出现毛石症,差异具有统计学意义（P ＜0.05）.结论利用阑尾黏膜预制尿道行阴茎再造术,方法可行;为避免尿道狭窄并发症的发生,宜根据尿道内上皮化生程度,调整合适的尿道预制时间.     

Urethral reconstruction using the radial forearm free flap: experience in oncologic cases and gender reassignment

OBJECTIVES: Urethra reconstruction in men remains a complex problem, particularly in patients who have had previous amputation for penile tumour or who have undergone gender reassignment. Many reconstructive techniques currently in use recreate the urethra but are prone to recurrent stricture formation and fail to achieve micturition with a good stream when standing. The authors propose using the radial forearm fasciocutaneous free flap as a single-stage technique of male urethral reconstruction. METHODS: During 1999-2004, nine patients underwent microsurgical reconstruction of the male urethra using the radial forearm fasciocutaneous free flap. Three patients underwent urethral reconstruction following previous subcutaneous penectomy for penile cancer. Another six patients had urethral reconstruction performed after failure of primary urethra construction as part of their gender reassignment surgery. RESULTS: The average age at the time of surgery was 35.1 yr (range: 22-55 yr) and average follow-up time was 41.8 mo (range: 13-55 mo). Flap reconstruction was successful in all cases, with no instances of free flap failure; however, two patients developed significant stenosis requiring revision, and no patients had postoperative fistula formation. Therefore, the success rate for urethral reconstruction after the first operation was seven of nine. Two patients with stenosis were treated operatively to release strictures with local flaps. Uroflowmetry demonstrated that these patients had satisfactory flow rates. CONCLUSION: Patient satisfaction and objective studies have demonstrated that urethral reconstruction with the use of radial forearm free flap is a good reconstructive procedure particularly when the patients need an extensive and long urethral reconstruction.     

Infection-induced urethral defect treated by urethral reconstruction with a radial forearm flap

Abstract A 47-year-old man was admitted with the chief complaint of a urethral defect. An approximately 17-cm defect of the urethra seemed to have been occurred by the infection of implanted foreign bodies in the penile skin. Reconstruction of the urethra and the ventral skin was performed with a free radial forearm flap. A fistula formed at the proximal anastomosis after the operation, but was controlled conservatively. Urethral stricture at the proximal anastomosis subsequently developed. A urethral stent made of shape memory alloy was placed with the preservation of voiding function.     

Review of microsurgical posterior urethral reconstruction

Posterior urethra reconstruction can be a challenging proposition for both patient and surgeon. The vast majority of urethras can be successfully reconstructed with either anastomosis or grafting. However, there are some patients who have recurrent urethral strictures that require more complex reconstruction. There is some speculation that microsurgical penile revascularization may allow subsequent graft reconstruction with lower stricture rates, but this is not yet proven. For the most tenacious urethral strictures, free tissue transfer may be required. The free radial forearm flap is well suited for urethral reconstruction, and the free anterolateral thigh flap may also have a role for these patients. This article will review urethral trauma and strictures and microsurgery's role in reconstruction of the posterior urethra.     

冻干脱细胞膀胱黏膜下基质在尿道下裂修复中的临床应用

目的在动物实验的基础上,将异体脱细胞膀胱黏膜下基质用于修复阴茎型尿道下裂患者,以初步了解其临床疗效。方法我们采用反复冻融—酶法获得了同种异体人脱细胞膀胱黏膜下基质,于2004年将其试用于3例尿道下裂患者的治疗。结果一期手术2例,尿线粗、直,无尿瘘,无散射;术后1年随访,阴茎无下弯,无尿痛、尿瘘,尿线粗,尿流测定仪及尿道镜检查未见异常。二期手术1例,远端尿道未见狭窄及闭锁。结论同种异体脱细胞膀胱黏膜下基质是一种有前途的较为理想的尿道组织修复替代材料,远期效果还有待继续进行严密仔细的观察。     

Changing practice in anterior urethroplasty

OBJECTIVE: To describe our experience of penile urethral repair and reconstruction, cataloguing the change in practice from one-stage flap to two-stage free graft procedures for anterior urethroplasty. PATIENTS AND METHODS: Between January 1992 and December 1996, 79 patients underwent anterior urethroplasty. Of the 45 one-stage bulbar patch urethroplasties, 37 (76%) used buccal mucosal free grafts rather than flaps. Of the 34 penile urethroplasties, 26 (82%) (including all of the circumferential reconstructions) were two-stage procedures. RESULTS: Buccal mucosal free grafts were at least as good as local skin flaps for patch urethroplasty and two-stage repairs gave much better results than one-stage repairs for total circumferential reconstruction of the penile urethra. CONCLUSIONS: For a patch urethroplasty of an uncomplicated stricture in the bulbar urethra, buccal mucosal free grafts are now the material of choice. For a patch urethroplasty of an uncomplicated stricture in the penile urethra the Orandi procedure remains the 'gold standard'. For a circumferential repair of the urethra, particularly the penile urethra, a two-stage repair using a free graft gives better results than a one-stage repair using a flap.     

Bhat's modifications of Glassberg–Duckett repair to reduce complications in management severe hypospadias with curvature

ObjectiveDisadvantages of two-stage hypospadias repair are the necessity of 2 or 3 surgeries, loss of time/money, complications like splaying of the stream, dribbling of urine or ejaculate and milking of the ejaculate due to a poor-quality urethra. The current article details our modifications of flap repair allowing to manage such patients in one stage and reducing the complications.Subjects and methodsTwenty one patients (aged 2–23 years, between January 2006 and June 2012 mean 11.5 years) of severe hypospadias were managed with flap tube urethroplasty combined with TIP since June 2006 and June 2012. Curvature was corrected by penile de-gloving, mobilization of urethral plate/urethra with corpus spongiosum and transecting urethral plate at corona. Buck's fascia was dissected between the corporeal bodies and superficial corporotomies were done as required. Mobilized urethral plate was tubularized to reconstruct proximal urethra up to peno-scrotal junction and distal tube was reconstructed with raised inner preputial flap after measuring adequacy of skin width. Both neo-urethrae were anastomosed in elliptical shape and covered with spongiosum. Distal anastomosis was done 5–8 mm proximal to tip of glans preventing protrusion of skin on glans. Tubularized urethral plate was covered by spongioplasty. Skin tube was covered by dartos pedicle and fixed to corpora. Scrotoplasty was done in layers, covering the anastomosis.ResultsType of hypospadias was scrotal 10, perineo-scrotal 5, penoscrotal 4 and proximal penile in 2 cases. Chordee (severe 15 and moderate 6) correction was possible penile de-gloving with mobilization of urethral plate with spongiosum after dividing urethral plate at corona 8, next 5 cases required dissection of corporal bodies, superficial corporotomy 5 and 3 cases lateral dissection of Buck's fascia. Length of tubularized urethral plate varied from 3 to 5 cm and flap tube varied from 5.5 to 13 cm (average 7.5 cm). Complications were fistula 2, meatal stenosis 1, and dilated distal urethra1 with overall success rate of 81%. None of them had residual curvature, torsion, splaying or dribbling urine in follow up of 10–36 (average 18) months.ConclusionsTIPU with spongioplasty of proximal urethra and dartos cover on skin tube reconstructs functional urethra. Distal end skin sutured to glans mucosa 5–8 mm proximal to the tip of glans reconstructs a cosmetically normal looking meatus. An exact measurement of the width and length of the stretched dartos, fixation of the skin tube to the corpora and covering the skin tube with dartos helps in prevention of diverticula. Elliptical anastomosis covered with spongiosum prevents fistula and stricture at anastomotic site.     

The surgical management of obstructive stents used for urethral strictures

PURPOSE: We present our referral experience with patients who had extensive urethral obstruction following UroLume insertion and were treated with urethroplasty. MATERIALS AND METHODS: We retrospectively analyzed the records of 13 men with urethral stricture who experienced recurrent obstruction following placement of a UroLume endoprosthesis. In all patients several attempts at urethral dilation and optical urethrotomy failed to overcome the obstruction. Complete excision of the obstructed urethra containing the stent with the surrounding periurethral fibrosis was done in all patients. In 12 patients a 1-stage bipedicled penile island tubularized flap was used to bridge the urethral defect. In 1 patient 1-stage urethroplasty was performed and he is awaiting stage 2. Followup assessment included urine flow, post-void residual urine measurement, retrograde urethrogram and urethroscopy at different intervals. RESULTS: Of the 12 patients who underwent complete treatment 1 had a short segment stricture at the site of the distal anastomosis 3 months after catheter removal, which was successfully managed by internal urethrotomy. He was doing well at the 12-month followup. In 11 patients a successful outcome was noted immediately after catheter removal and it was maintained at a mean followup of 1.8 years (range 1 to 4). CONCLUSIONS: Complete excision of the obstructed urethra containing the UroLume stent with the surrounding periurethral fibrosis is an important first step in reconstruction. Subsequent use of a 1-stage bipedicled penile island tubularized flap resulted in excellent long-term results. In a small subset of cases delayed stage 2 repair after skin inlay is a valuable option.