长隧道带蒂包皮内板尿道成形术治疗阴茎体型尿道下裂的疗效分析

目的 探讨长隧道带蒂包皮内板尿道成形术治疗阴茎体型尿道下裂的疗效. 方法 2007年9月至2010年4月收治阴茎体型尿道下裂患儿28例,年龄1.5 ～6.0岁,平均2.0岁.均行长隧道带蒂包皮内板尿道成形术.尿道开口均位于阴茎体部,距离阴茎头顶端16 ～ 37 mm,平均25immn;分离尿道及纠正阴茎下曲后尿道缺损30 ～ 42 mm,平均38 mm.手术要点:沿尿道开口环形切开阴茎皮肤,分离至尿道板,横断尿道板,沿尿道板与海绵体之间分离隧道至阴茎头正中,隧道长度26～38 mm,平均33 mm.尿道开口至阴茎头之间全程由隧道贯通,尽量保持阴茎腹侧皮肤与组织完整,取带蒂包皮内板制作新尿道,将新尿道通过阴茎侧方深筋膜下通道转移至腹侧隧道进行吻合.术中人工勃起试验证实合并轻度阴茎下曲13例,无明显阴茎下曲15例. 结果 28例均一期修复成功,手术时间50～70 min,平均55min.随访时间6～31个月,平均20个月.28例患儿均排尿通畅,尿线粗直.尿道呈矢状开口于阴茎头正中,阴茎下曲纠正满意,外观好,未发生尿瘘或狭窄. 结论 长隧道带蒂包皮内板尿道成形术适用于无或合并轻度阴茎下曲的阴茎体型尿道下裂,尤其适合年龄小或阴茎体细小患儿,手术简单,效果好,外观满意.     

Correction of completely buried penis using the modified preputial island pedicle flap method.

The buried penis is a rare congenital abnormality caused by a deficiency of penile shaft skin and abnormal attachments of the dartos fascia to Buck's fascia. The basis for surgical correction is directed at freeing the penile shaft from abnormal dartos attachments, refixing dartos fascia to Buck's fascia to prevent retraction of the penis, and providing adequate shaft skin coverage with the inner preputial skin. The authors report a modified preputial island pedicle flap method for correcting the completely buried penis performed on 2 patients (ages 9 months and 1 year) at Nagoya City University Medical School.     

纵行阴茎腹外侧肉膜瓣在远端尿道下裂Ⅰ期修复术中的应用

目的:探讨阴茎纵行腹外侧肉膜瓣在远端尿道下裂Ⅰ期修复术中的应用价值。方法:对55例阴茎远端型尿道下裂患者先行尿道板纵切卷管尿道成形术(TIP)修复尿道,然后采用阴茎纵行腹外侧阴茎肉膜瓣对修复新尿道进行覆盖。结果:55例患者均获得类似包皮环切术后样外观,尿道外口开口于阴茎头顶端呈裂隙状;仅4例(7.3%)于冠状沟处发生尿道瘘。结论:在远端尿道下裂Ⅰ期修复术中,以阴茎纵行腹外侧肉膜瓣对新尿道加以覆盖,能有效降低尿道瘘的发生率,且修复后阴茎获得类似包皮环切术后样外观。     

Use of a vertical island flap for correction of epispadias.

An 18-year-old man presented with epispadias. His main complaints were dorsal curvature of the penis and difficulties during erection and micturition. Primary urethroplasty at another hospital had been only minimally successful. The public bones were normal and he was continent. He was treated by complete excision of the chordee and urethroplasty. Local flaps were used to reconstruct the glandular urethra, and a vertical penile island flap was used to replace the missing portion of the penile urethra. Good straightening of the penis and a new urethra with a well-closed meatus at the tip of the glans were achieved in a single-stage operation. No complication occurred, and the result was satisfactory from both the aesthetic and functional points of view.     

Penile torsion repair using dorsal dartos flap rotation

PURPOSE: Counterclockwise penile torsion is a frequently noted congenital deformity. Previously proposed techniques of torsion repair are ineffective or pose significant operative risks. We introduce a novel technique using dorsal dartos flap rotation. MATERIALS AND METHODS: The penis is first degloved completely and a broad based dartos flap is mobilized from the dorsal penile skin. The flap is rotated around the right side of the penile shaft and attached to the ventral aspect, causing clockwise penile rotation. Final slight adjustments are made during skin closure. We applied this technique in 8 patients undergoing circumcision (2), chordee (4) or hypospadias (2) repair. RESULTS: This technique was effective for correcting penile torsion in all patients. At a mean followup of 8.3 months the cosmetic outcome was satisfactory with the complete correction of penile torsion. CONCLUSIONS: Rotational repositioning of a dorsal dartos flap is an effective technique for correcting penile torsion and it is easily applicable with other penile reconstruction procedures.     

小儿先天性无尿道下裂阴茎下曲畸形的解剖特点及诊治

目的探讨小儿先天性无尿道下裂阴茎下曲畸形的解剖特点及诊治.方法 1984年8月～2004年12月,对94例先天性无尿道下裂阴茎下曲畸形的青春期前患儿进行分类并观察病变解剖特征.年龄18个月～13岁,平均6.9岁.对阴茎下曲明显,弯曲度超过30°者,采用手术治疗.结果Ⅰ型(皮肤型)31例,腹侧皮肤短缩或伴有浅筋膜挛缩,部分呈蹼状阴茎,环切脱套分离后阴茎伸直;Ⅱ型(筋膜型)45例,尿道浅面有明显增厚的纤维索带组织限制阴茎伸直,脱套后需切除纤维索带组织才能伸直阴茎;Ⅲ型(海绵体型)6例,海绵体背、腹侧不对称,尿道与腹侧海绵体紧贴,无明显弓弦关系,作背侧白膜折叠可伸直阴茎;Ⅳ型(尿道型)12例,尿道发育不良,与阴茎海绵体呈明显弓弦关系,需重建尿道才能伸直阴茎.术后阴茎长度增加(术前平均5.2 cm,术后平均6.9 cm),弯曲矫正充分(术前平均42.6°,术后平均1.6 °).术后随访1个月～15年,有2例残留弯曲,2例尿瘘,2例尿道狭窄,1例尿瘘合并尿道狭窄和憩室;再手术后矫正满意.结论在先天性无尿道下裂阴茎下曲畸形中,不同组织层面的解剖学异常决定病变分型,术中应反复行人工勃起试验以明确下曲类型,并据以选择矫正术式.     

Review and update of the anatomy of the penis

The knowledge of penile anatomy is basic to perform a proper diagnosis and direct the most adequate treatment of the various diseases that may appear: urethral stenosis, erectile dysfunction, congenital or acquired penile curvature, etc.; being its anatomical knowledge essential for a proper surgical management. The penis is the male organ involved in both voiding and sexual functions: the body of the penis is composed by three erectile bodies, (i.e the deep structures): the corpora cavernosa and the corpus spongiosum, this last surrounding and covering the urethra. Buck's fascia is in relation to the deep structures of the penis. The superficial fascia, dartos, is made up from a more areolar tissue and is in relation to skin and vessels. The vascularization of the deep structures comes from the common penile artery, a branch of the internal pudendal artery. Penile blood drains through three venous systems: superficial, intermediate and deep systems. Pudendal nerves are in charge of the sensitive and motor somatic innervations. Cavernosal nerves are a combination of parasympathetic and sympathetic afferent fibers, corresponding to the nerves of the autonomic system of the penis.     

Management of chordee in children and young adults

Penile curvature is a spectrum of disease affecting boys with and without hypospadias. The etiology of chordee includes skin tethering, fibrotic bucks or dartos fascia, corporeal body disproportion and rarely a fibrotic urethra. Several surgical techniques (plication, excision, and graft insertion) are currently employed to repair penile curvature. Recent neuroanatomical studies of the developing fetal penis have shown that the dorsal nerve branches from the 11 and 1 o'clock positions to the 5 and 7 o'clock positions, being absent in the midline. Since the neuroanatomy is similar in both the hypospadiac and normal penis, we now recommend performing penile straightening in both hypospadiac and non hypospadiac patients with significant curvature by the placement of plication sutures at the 12 o'clock position. Placement of dorsal midline plication sutures corrects curvature without risk to the underlying nerve structures.     

成人尿道下裂分期手术探讨

目的:探讨成人尿道下裂分期手术的必要性,提高成人尿道下裂的手术成功率。方法:回顾性分析我院泌尿外科2004年1月至2012年1月收治成人尿道下裂患者52例。52例男性患者,平均年龄22岁,所有患者过去均有尿道成形手术史,患者局部阴茎皮肤有瘢痕组织,均有阴茎下弯。术中行阴茎包皮脱鞘切除腹侧瘢痕纤维索带切断尿道板,仍存在阴茎下弯患者行阴茎背侧海绵体白膜折叠伸直阴茎,伸直阴茎后前尿道缺损长度占阴茎长度比例大于50%。根据术中是否行分期手术将患者分为两组,1组(20例)患者行I期包皮带蒂皮瓣卷管术尿道成型,2组(32例)患者阴茎伸直后将整个阴茎多余包皮转移至腹侧,做成形缝合为II期尿道成型预留尿道板,6¹2个月后行阴茎腹侧皮管卷管尿道成形术。结果:两组患者分别在Ⅰ期和Ⅱ期尿道成形术后发生尿瘘比例为50%、21.9%,尿道狭窄15%、9.4%,伤口感染30%、25%,尿道裂开20%、12.5%,尿道成形手术成功率分别为25%、56.3%。两组尿道成形术后发生尿瘘和尿道成形成功率的差异有统计学意义(P<0.05),术后发生尿道狭窄、伤口感染及尿道裂开并发症的差异无统计学意义。结论:对有尿道下裂手术史的成人患者,尤其对那些阴茎下弯明显,前尿道缺损长且局部包皮材料不足的患者分期手术更适合,Ⅱ期尿道成形的成功率得到提高。     

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.     

Split-thickness skin graft for the management of concealed penis

PURPOSE: We review the use of split-thickness skin grafting in children with concealed penis. MATERIALS AND METHODS: Medical records were retrospectively reviewed for all patients younger than 20 years seen at our institution from 1995 to 2003 with a diagnosis of concealed penis. Patients were separated into "primary" and "secondary" groups based on the cause of concealment. Primary factors were prominent prepubic fat pad, dysgenetic dartos fascia or both. Secondary factors were post-circumcision phimosis and overzealous circumcision. RESULTS: A total of 26 patients 1 month to 19 years old were treated. In the primary group of 23 patients 11 underwent lysis of dartos fascia. Four of these 11 patients had insufficient skin, and split-thickness skin grafting was necessary to resurface the penile shaft. Five of the patients underwent excision of the fat pad only, and 2 underwent excision of the fat pad and lysis of fascia. Five patients are being observed. Of the 3 patients in the secondary group 1 underwent manual reduction of post-circumcision phimosis, 1 underwent scrotal flaps and 1 is being observed. Followup ranged from 2 weeks to 46 months (mean 13 months). Of 20 surgically repaired patients 19 (95%) had an excellent cosmetic result, were satisfied with penile length and reported no voiding complaints. CONCLUSIONS: The surgical approach for correcting concealed penis varies, depending on the cause. Of our 26 patients 4 (15%) had insufficient penile skin to resurface the penile shaft. In these select children split-thickness skin grafting provided a good cosmetic appearance and functional result.     

The dartos musculocutaneous island flap in urethral reconstruction

Reconstruction of the burned penile urethra has received scant attention in the surgical literature. Techniques used in repairing congenital hypospadias may not be applicable in this situation. We describe a dartos musculocutaneous island flap used to reconstruct the distal burned penile urethra in a 13-year-old boy who sustained burns to 85% of his total body surface area. Reconstruction was completed in one surgical procedure, and at two-year follow-up good results were demonstrated.     

Split onlay skin flap for the salvage hypospadias repair

PURPOSE: Following failed hypospadias repair absence of the penile foreskin, a shortage of ventral skin and residual chordee may all contribute to poor long-term results. We describe a technique called the split onlay skin (SOS) flap that has improved our surgical outcomes in boys requiring salvage hypospadias repair. MATERIALS AND METHODS: The SOS flap uses a transverse island of penile shaft skin that is mobilized on its vascular pedicle and rotated into position to the ventrum of the penis at the site of the urethral defect. The flap is transected transversely, and half of the flap is used as an onlay to repair the urethra and the other half is used for additional skin coverage where needed on the penile shaft. We treated 11 boys 30 to 124 months old (mean age 60.3 months) who had a mean of 2 previous failed hypospadias repairs. All 11 boys presented with complex combinations of urethrocutaneous fistulas, stricture or urethral diverticula. RESULTS: Of the 11 patients 6 (54.5%) had development of postoperative fistulas. Five of these fistulas were surgically closed with no further complications. One penoscrotal fistula closed spontaneously after 7 months. Mild chordee from contraction of the flap and a urethral diverticulum developed in 1 boy. At a mean followup of 24.5 months all patients, including those who underwent closure of the secondary fistula, were voiding well with excellent appearance. CONCLUSIONS: In cases where little local tissue is present the SOS flap procedure is an excellent way to transfer healthy dorsal tissue to the ventrum for an onlay salvage urethroplasty while providing additional coverage of the urethral defect and a tension-free skin closure. Despite the high fistula rate we encountered following the initial SOS procedure, we endorse this technique because the transferred dartos provides additional tissue, which facilitates subsequent fistula repair. These boys can achieve a successful cosmetic result without incorporation of scrotal tissue or a free graft, which we believe leads to more predictable results.     

斜行包皮岛状皮瓣尿道成形术治疗尿道下裂

目的:探讨斜行包皮岛状皮瓣尿道成形术治疗尿道下裂的效果。方法:采用斜行包皮岛状皮瓣尿道成形术治疗尿道下裂51例。结果:所有病例均自正位尿道口排尿,尿道外口呈纵向裂隙状,阴茎的外观满意,无阴茎下弯或侧弯,并发症发生率11.8%(6/51),其中尿瘘3例,尿道外口狭窄3例。结论:本术式具有取材范围大、皮瓣血运可靠、成形阴茎外观满意、并发症少等优点,适合阴茎型和阴茎-阴囊型尿道下裂的I期修复。     

Complete repair of bladder exstrophy: management of resultant hypospadias

PURPOSE: In our hands complete primary repair (CPR) of bladder exstrophy results in hypospadias in two-thirds of boys. To our knowledge hypospadias repair following CPR of bladder exstrophy has not been reported previously. We report our experience with hypospadias repair following CPR of bladder exstrophy. MATERIALS AND METHODS: A total of 22 boys with bladder exstrophy underwent CPR using Mitchell's technique between November 1998 and January 2002. The procedure resulted in hypospadias in 15 boys (68%). The site of the meatus was distal penile in 5 patients, mid penile in 3 and proximal penile in 7. Hypospadias repair was performed in all 15 boys. The 5 patients with distal penile hypospadias underwent repair consisting of Thiersch-Duplay urethroplasty with dorsal incision in 3 and tubularized vertical island flap with glanular tunnel in 2. All patients with mid (3) or proximal (7) penile hypospadias underwent Mustarde repair with glanular tunnel. RESULTS: Followup ranged from 6 to 18 months (median 13). The Thiersch-Duplay procedure with dorsal incision resulted in fistula/stenosis in 2 of 3 boys. None of the remaining 12 boys with tubularized penile flap urethroplasty (tubularized vertical island flap or Mustarde) with glanular tunneling had development of fistula or stenosis. Complete degloving of the penis and penile skin redistribution were not necessary with the Mustarde technique. CONCLUSIONS: Thiersch-Duplay urethroplasty with dorsal incision does not seem to be a good option for hypospadias repair following CPR of bladder exstrophy. The use of penile skin as a tubularized flap with glanular tunneling seems to yield excellent functional/cosmetic results.     

A new approach in hypospadias repair

The field of hypospadiology remains full of challenges in the search for new and better solutions. In recent years, our concept has involved being very radical in penile reconstructive surgery, using an aggressive approach. The penile disassembly technique, either complete or incomplete, is used successfully in epispadias repair. We began using penile disassembly in hypospadias repair in November 1995. The technique was applied on 112 patients aged from 9 months to 32 years. Indications were: hypospadias with severe penile curvature (especially when the curvature was located in the distal third of the corpora cavernosa), chordee without hypospadias, and small penises with hypospadias. The principle of the technique involves separation of the penis into its component parts: the glans cap with neurovascular bundle (dorsally) together with the nondivided or divided urethra and urethral plate (ventrally) and the corpora cavernosa. This maneuver enables an excellent correction of curvature, especially if it is located in the distal third of the corporal bodies and glans tilt. With this technique, substitution urethroplasty can be avoided or its extent, decreased. It enables penile enlargement, above all its lengthening, which is a significant gain in small penises with hypospadias. The patients were followed for 3–23 months (mean 16 months). Straightening of the penis was achieved in all cases without recurrence of curvature. In 37 patients penile disassembly combined with extensive urethral mobilization solved the problem of hypospadiac meatus without the need to form a neourethra. Complications related to urethroplasty included four urethral stenoses, two fistulas, and three diverticula. There was no injury to the neurovascular bundle and urethra. Sensitivity and erection were preserved in all patients. Penile disassembly is an optimal technique for repair of hypospadias with severe curvature and small hypospadiac penises. Real penile augmentation is possible with this technique.     

Tunica albuginea plication for the correction of penile curvature

OBJECTIVE: To evaluate the efficacy of tunica albuginea plication (TAP) in the correction of congenital and acquired penile curvatures and determine key points for a successful outcome of this procedure. MATERIALS AND METHODS: From December 1995 to January 2001, 40 patients with penile curvature (10 congenital and 30 secondary to Peyronie's disease) underwent surgical correction by TAP. Indications were difficult or impossible penetration, normal erectile function, stable disease. For TAP we used non-absorbable inverted stitches tied with the assistant pushing down the tunica albuginea with a mosquito clamp to create an adequate groove for the knot. The results were evaluated subjectively and objectively. RESULTS: At mean follow-up of 30 months, full subjective and objective success (straight penis, mild shortening, normal erection, penetration and sensation) was achieved in 37 (92.5%) patients. Objective but not subjective success was achieved in 2 patients (5%), 1 complaining of psychogenic erectile dysfunction and the other of excessive penile shortening. There was only one failure, namely persistent glans numbness due to damage of the non-mobilized neurovascular bundle. CONCLUSIONS: TAP is a simple and effective method for the correction of congenital and acquired penile curvatures. Key points for successful outcome are adequate preoperative evaluation and counselling, careful preparation of tunica albuginea, mobilization of urethra or neurovascular bundle when needed, use of inverted stitches carefully buried, objective postoperative evaluation with a pharmacological erection test.     

应用阴囊肉膜平滑肌肌皮瓣修复阴茎延长术中的阴茎创面

目的 提供理想的阴茎延长术中阴茎创面的修复组织。方法 在阴茎1阴阜区皮肤交界处切开、切断阴茎浅悬韧带和部分阴茎深悬韧带行阴茎延长术后，应用以阴囊前动、静脉为血管蒂的阴囊膜平滑肌肌皮瓣（下简称阴囊皮瓣）转移修复在阴茎根部所形成的创面。结果 1996年以来共应用于16例患者，阴茎平均延长4－4．5cm，阴囊皮瓣全部成活，阴茎形态满意，阴囊无明显变形。结论 阴囊皮瓣血运丰富，薄而无皮下脂肪，有伸缩性，是阴茎延长手术中阴茎皮肤缺损较好的修复方法之一。     

Dorsal tunica albuginea plication to correct congenital and acquired penile curvature: a long-term follow-up

OBJECTIVE: To evaluate the long-term efficacy of a tunica albuginea dorsal plication technique for treating congenital and acquired penile curvature. PATIENTS AND METHODS: We retrospectively evaluated 83 patients (median age 1.8 years) who had their penile curvature corrected surgically using dorsal tunica albuginea plication between 1992 and 2002. The results were evaluated objectively using a pharmacological erection test or subsequently based either on the parents' reports or patients' self-assessment. The median (range) follow-up was 6 (0.7-10) years. RESULTS: Seventy (84%) patients had penile plication as an integral part of hypospadias repair, while the remaining 13 (16%) with a normal urethra had dorsal plication only. Twenty-eight (34%) of the 83 patients had an erection test during a repeat hypospadias repair or closure of a urethrocutaneous fistula; 22 of these had a straight penis, while the remaining six required additional plication for a satisfactory cosmetic outcome. Parents of 45 (54%) children reported that their child had a normal erection with no chordee during the follow-up. Ten (12%) adult patients reported straight erections enabling satisfactory penetration and sensation during sexual intercourse. None of the patients reported penile shortening or erectile dysfunction after surgery, and none had recurrent curvature during the follow-up. There was no difference in the results between patients with congenital or acquired penile curvature. CONCLUSIONS: Dorsal plication of the tunica albuginea is a simple and effective method in the long term for correcting congenital and acquired penile curvature.     

尿道下裂术后尿道狭窄在青春期后的处理经验(附71例报告)

目的:探讨尿道下裂术后尿道狭窄在青春期后的处理经验。方法:回顾性分析2015年1月至2019年12月上海交通大学附属第六人民医院收治的71例青春期后就诊的尿道下裂术后尿道狭窄患者的临床资料。年龄平均27.7(12～65)岁;病程平均33.4(1～240)个月。既往手术次数平均2.5(1～9)次;尿道异位开口32例,其中...