复杂性前尿道狭窄的治疗(附78例报告)

目的　探讨复杂性前尿道狭窄手术方法的选择及成功的关键。　方法　对 78例复杂性前尿道狭窄患者采用不同手术方法的尿道成形术 ,其中不同黏膜重建尿道 4 0例 ,带蒂皮瓣一期尿道成形 2 6例 ,狭窄段尿道劈开、二期尿道成形 (Johanson术 ) 12例。　结果　术后随访 6～ 36个月 ,平均 16 .5个月。 6 7例排尿通畅 ,11例效果欠佳。其中黏膜重建尿道组发生尿道皮肤瘘 1例 ,尿道外口狭窄 2例 ,阴茎弯曲 1例 ;带蒂皮瓣尿道成形组发生尿道狭窄 3例 ,尿道皮肤瘘 1例 ,尿道皮肤瘘合并成形段尿道内毛发生成和结石形成 1例 ;Johanson术组发生阴茎弯曲 2例 ,其中 1例合并成形段尿道内毛发生成。　结论　复杂性前尿道狭窄手术方法的选择应根据尿道狭窄段长短、位置和严重程度。尿道狭窄段 <8～ 10cm者宜选用阴茎皮肤 (包括包皮 )带蒂皮瓣 ,阴茎皮肤取材有困难时可选用膀胱或口腔黏膜 ;尿道狭窄段 >10cm者可选用结肠黏膜 ,尤其在膀胱黏膜取材有困难时。     

复杂性尿道下裂修复失败后的治疗

目的 探讨不同游离黏膜、带蒂皮瓣或二种组织拼接尿道成形术治疗复杂性尿道下裂修复失败后病例的效果.方法 采用3种游离黏膜或带蒂阴茎皮瓣尿道成形治疗尿道下裂修复失败后患者36例,其中带蒂阴茎皮瓣尿道成形7例,舌黏膜与阴茎皮瓣拼接重建尿道3例.结肠黏膜重建尿道2例,1条舌黏膜重建尿道9例,1条颊黏膜重建尿道7例,采用2条口腔内黏膜拼接重建尿道8例.阴茎用弹力绷带包扎4 d,每天用抗生素液冲洗尿道1次.结果 36例术后随访3～84个月,平均32.6个月.术后2～3周发牛尿瘘4例.术后2～3个月新尿道发生狭窄3例,其中吻合口狭窄1例.经尿道扩张5次后排尿通畅;尿道外口狭窄2例,经手术矫正后均排尿通畅,Q_(max)分别为37.3和28.7 ml/s.余者排尿通畅,尿线粗,Q_(max) 18.0～46.0 ml/s,平均26.8 ml/s.结论 舌黏膜与颊黏膜具有取材方便、创伤小的特点,较适合于尿道下裂修复失败后皮源少患者的尿道重建.     

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。     

结肠黏膜重建尿道治疗复杂性超长段尿道狭窄

目的:探讨结肠黏膜重建尿道治疗复杂性超长段尿道狭窄的应用价值与疗效.方法:对既往已有平均2.5次不成功的尿道修复史的35例患者,采用结肠黏膜一期尿道成形术,治疗其复杂性超长段尿道狭窄.所用结肠黏膜重建的尿道长10～20cm,平均14.6cm.术后分别行尿道造影,检测尿流率,部分患者行尿道镜检查.结果:患者术后随访3～60个月,平均28.5个月.31例术后排尿通畅,最大尿流率大于15 ml/s.1例因结肠黏膜新尿道与前列腺部尿道吻合区血供较差,术后继发尿道狭窄;1例在术后3个月并发尿道外口狭窄,经手术矫正后排尿通畅;2例分别在术后46,20个月时发生与重建尿道无关的球膜部尿道狭窄,采用口腔黏膜尿道成形术后排尿通畅.结论:利用结肠黏膜重建尿道治疗复杂性超长段尿道狭窄或闭锁,是一种可行而有效的方法,尤其是适合在较多常规方法治疗失败者.     

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.     

舌黏膜尿道成形治疗前尿道狭窄（附80例报告）

目的：研究舌黏膜尿道成形治疗尿道狭窄的有效性和安全性。方法：2006年8月～2008年12月采用舌黏膜尿道成形治疗80例前尿道狭窄,尿道狭窄段2．5～18cm,其中30例为长段尿道狭窄（9～18cm）采用双侧舌黏膜或舌黏膜与颊黏膜或与带蒂包皮拼接尿道成形治疗。尿道成形采用两种术式：保留原尿道板的扩大尿道腔37例;埋藏黏膜条43例。结果：术后随访4～30（平均16．8）个月,7例发生并发症,其中尿瘘4例,再次发生尿道狭窄3例,其余患者排尿通畅,最大尿流率从15．2～54．6（平均28．7）ml／s。结论：舌黏膜是一种修复前尿道狭窄较好的尿道替代物,双侧舌黏膜尿道成形能成功治疗长段、复杂性尿道狭窄。     

游离黏膜尿道成形治疗硬化性苔藓样病所致尿道狭窄的疗效观察

目的 提高对硬化性苔藓样病( lichen sclerosus,LS)导致尿道狭窄的认识,观察游离黏膜尿道成形治疗LS所致尿道狭窄的疗效. 方法 2007年1月-2010年12月收治LS所致前尿道狭窄患者36例,年龄27～75岁,平均41岁.尿道狭窄段长5.0 ～20.0 cm,平均11.5 cm.根据尿道狭窄段长短和严重程度选择不同的黏膜组织,其中行口腔内黏膜(舌、颊黏膜)尿道成形27例,结肠黏膜尿道成形8例,另1例老年患者行前尿道劈开.在行尿道重建术前对病变累及的阴茎头、尿道口、尿道行病理学检查. 结果 36例患者术后3周拔除导尿管,排尿通畅;活检结果提示上皮基底部特征性病变,过度角化,上皮层变薄,淋巴细胞浸润等.术后随访6 ～ 50个月,平均22个月.出现尿道外口狭窄3例(8.3％),其中口腔内黏膜尿道成形者2例,结肠黏膜重建尿道者1例,行尿道外口切开后排尿通畅.余患者术后排尿通畅,最大尿流率17.2～47.0 ml/s,平均23.4 ml/s. 结论 采用游离黏膜尿道成形治疗LS所致尿道狭窄疗效较好,但需密切随访,因病变迁延可致尿道再狭窄,尤其是尿道口再狭窄.     

结肠黏膜尿道成形治疗复杂性超长段尿道狭窄的长期疗效

目的 观察结肠黏膜尿道成形术治疗复杂性超长段尿道狭窄的长期效果和影响因素. 方法 2000年10月至2009年9月采用结肠黏膜尿道成形治疗复杂性超长段尿道狭窄46例.年龄17 ～70岁,平均39岁.尿道狭窄段长10.0～20.0 cm,平均15.2 cm.术前有平均2.7次不成功的尿道修复史.通过定期门诊或电话随访进行术后疗效评估,包括排尿情况和尿流率检查,部分患者行尿道造影和尿道镜检查等.以不需要任何处理包括尿道扩张,能正常排尿,尿流率在正常范围内者视为手术成功. 结果 结肠黏膜重建尿道的长度为11.0～21.0 cm,平均15.4 cm.1例失访,余45例随访20～120个月,平均62个月.发生与手术相关的并发症4例(8.9％),其中3例于术后3、8和24个月发生尿道外口狭窄,1例术后29个月发生结肠黏膜新尿道与尿道近端吻合口狭窄.另2例发生与结肠黏膜尿道成形术无关的尿道狭窄. 结论 结肠黏膜尿道成形术治疗复杂性超长段尿道狭窄术后长期效果理想;影响术后效果的因素是尿道口狭窄和吻合口狭窄.     

影响口腔黏膜尿道成形治疗复杂性尿道狭窄疗效的相关因素

目的：探讨口腔黏膜尿道成形治疗复杂性尿道狭窄影响疗效的相关因素。方法：对采用口腔黏膜替代尿道成形术76例患者的尿道狭窄位置与长度、口腔黏膜宽度、术前手术次数、支架管留置时间等与狭窄复发率进行单因素分析。结果：76例随访3～60个月,平均24．1个月,术后初期排尿通畅61例（80．3％）;再次狭窄15例,其中3例同时伴尿道皮肤瘘,4例伴尿道假性憩室。2例经数次尿道扩张、8例再次手术后排尿通畅,总成功率为93．4％。结论：尿道狭窄复发率与黏膜宽度明显相关（P〈0．05）。在0．8～2．0cm范围内口腔黏膜条越宽,尿道狭窄发生率越低;狭窄长度与术前手术次数对短期狭窄复发率无明显影响。     

Substitution urethroplasty of complex and long-segment urethral strictures: a rationale for procedure selection

OBJECTIVES: We evaluated the applications and outcomes of substitution urethroplasty, using a variety of techniques, in 65 patients with complex, long-segment urethral strictures. METHODS: From January 1995 to December 2005, 65 patients with complex urethral strictures >8cm in length underwent substitution urethroplasty. Of the 65 patients, 43 underwent one-stage urethral reconstruction using mucosal grafts (28 colonic mucosal graft, 12 buccal mucosal graft, and 3 bladder mucosal graft), 17 patients underwent one-stage urethroplasty using pedicle flaps, and 5 patients underwent staged Johanson's urethroplasty. RESULTS: The mean follow-up time was 4.8 yr (range; 0.8-10 yr), with an overall success rate of 76.92% (50 of 65 cases). Complications developed in 15 patients (23.08%) and included recurrent stricture in 7 (10.77%), urethrocutaneous fistula in 3 (4.62%), coloabdominal fistula in 1 (1.54%), penile chordee in 2 (3.08%), and urethral pseudodiverticulum in 2 (3.08%). Recurrent strictures and urethral pseudodiverticulum were treated successfully with a subsequent procedure, including repeat urethroplasty in six cases and urethrotomy or dilation in three. Coloabdominal fistula was corrected only by dressing change; five patients await further reconstruction. CONCLUSIONS: Penile skin, colonic mucosal, and buccal mucosal grafts are excellent materials for substitution urethroplasty. Colonic mucosal graft urethroplasty is a feasible procedure for complicated urethral strictures involving the entire or multiple portions of the urethra and the technique may also be considered for urethral reconstruction in patients in whom other conventional procedures failed.     

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.     

Substitution urethroplasty for anterior urethral strictures: a critical appraisal of various techniques

OBJECTIVE: To retrospectively compare the outcome of various techniques of substitution urethroplasty. PATIENTS AND METHODS: Between 1989 and 2000, 109 patients (mean age 39.5 years) underwent substitution urethroplasty for recurrent anterior urethral strictures. Between 1989 and 1995 the procedure was by ventral placement of free grafts (bladder mucosa, buccal mucosa, penile skin) or penile skin flaps. From 1995 onwards the flaps and grafts (buccal mucosa) were applied either ventrally or dorsally. Stricture recurrence and the complications associated with each technique were compared. RESULTS: Ventral onlay repairs were associated with a higher incidence of complications than dorsal repairs, e.g. postvoid dribbling (39% vs 23%, P = 0.01), ejaculatory dysfunction (20% vs 5%, P = 0.03) and flap/graft pseudo-diverticulum or out-pouching (26% vs 2.6%, P = 0.01). Superficial penile skin necrosis was significantly more common with the use of penile skin flaps than with free grafts. There was no significant difference in stricture recurrence, erectile dysfunction and residual penile deformity among the various techniques. CONCLUSIONS: Dorsal free graft/flap onlay urethroplasty gives better results than ventrally placed free grafts/flaps. Dorsal onlay buccal mucosal urethroplasty is a versatile procedure and associated with fewer complications than other substitution methods.     

Urethral plate salvage with dorsal graft promotes successful penile flap onlay reconstruction of severe pendulous strictures

PURPOSE: A modified 1-stage penile flap onlay reconstruction is presented for patients with a long stricture in whom the urethral plate is deficient or absent. MATERIALS AND METHODS: Of 37 patients who underwent transverse penile island flap onlay urethroplasty 3 men and 1 boy required simultaneous augmentation (2) or replacement (2) of an inadequate urethral plate. The 15-year-old boy had persistent severe chordee after multiple hypospadias procedures. A dorsal buccal mucosal graft was used in 3 cases and cadaveric dermal graft was used in 1. The goal of dorsal graft application in each case was to create a uniform urethral plate 1 cm. wide to promote successful 1-stage penile flap onlay reconstruction. RESULTS: No patient has required further instrumentation and all void without difficulty. In the 15-year-old boy chordee has completely resolved. CONCLUSIONS: Using dorsal grafts to salvage an inadequate urethral plate during 1-stage penile island flap onlay reconstruction obviates flap tubularization.     

A comparison of one-stage procedures for post-traumatic urethral stricture repair

OBJECTIVE: To compare the results and complication rates of various one-stage treatments for repairing a post-traumatic urethral stricture. PATIENTS AND METHODS: The medical records of 153 patients who had a post-traumatic urethral stricture repaired between 1977 and 2003 were evaluated retrospectively, and analysed for the different types of urethral reconstruction. RESULTS: The procedures included direct end-to-end anastomosis in 86 (56%) patients, free dorsal onlay graft urethroplasty using preputial or inguinal skin in 40 (26%), ventral onlay urethroplasty using buccal mucosa in seven (5%) and ventral fasciocutaneous flaps on a vascular pedicle in 20 (13%). At a mean (median, range) follow-up of 75.2 (38, 12-322) months, 121 (79%) patients had no evidence of recurrent stricture, while in 32 men (21%) they were detected at a mean follow-up of 30.47 (1-96) months. Patients having a dorsal onlay urethroplasty had the longest strictures. The re-stricture rate was lowest after a dorsal onlay urethroplasty (5% vs 27% when treated with end-to-end anastomosis, 15% after fasciocutaneous flaps and 57% after a ventral buccal mucosal graft). The surgical technique used had no effect on postoperative incontinence or erectile dysfunction rates. CONCLUSION: In patients with strictures which are too long to be excised and re-anastomosed, tension-free dorsal onlay urethroplasty is better than ventral graft or flap techniques. In patients with short urethral strictures direct end-to-end anastomosis remains an option for the one-stage repair of urethral stricture.     

Oral mucosal grafts urethroplasty for the treatment of long segmented anterior urethral strictures

Objective  To evaluate the efficacy and safety of using oral mucosal grafts for urethroplasty in the treatment of complex segmented urethral strictures. Methods  Between January 2002 and January 2008, 25 cases of long or multi-segmented urethral strictures (10–18 cm, mean 11.72) were treated using combined two oral mucosal graft urethroplasty. Of the 25 patients, combined double buccal mucosal graft (BMG) urethroplasty was performed in nine patients, double lingual mucosal graft (LMG) urethroplasty in seven patients and combined lingual and buccal mucosal graft urethroplasty in nine patients. Results  Follow-up was obtained for 6–72 months (mean 26.83) post-operatively. Urethrocutaneous fistulas developed in two patients. Urethral strictures developed in one patient undergoing BMG urethroplasty; the patient underwent five urethral dilations, after which he voided well with a urinary peak flow of 26.4 ml/s. Meatal stenosis developed in one patient undergoing LMG and a second operation was required, after which the patient voided well (urinary peak flow of 28.7 ml/s). The other patients voided well and urinary peak flow rates ranged from 16.8 to 49.2 ml/s (mean 28.65 ml/s). Conclusion  Combined two oral mucosal grafts substitution urethroplasty is an effective technique for the treatment of long, segmented urethral strictures.