联合远位组织再造尿道修复复杂尿道下裂

目的：探索并总结复杂尿道下裂的修复方法。方法：2003年6月至2006年12月对32例复杂尿道下裂分别采用阴股沟中厚皮片游离移植，口腔粘膜游离移植、口腔粘膜耦合局部皮瓣、阴股沟中厚皮片耦合局部皮瓣再造尿道4种方法修复各型复杂尿道下裂。结果：随访半年～2年，除2例尿漏外，其余病例阴茎形态良好，排尿正常，无一例发生尿道狭窄或憩室，供区无明显畸形。结论：对于复杂的尿道下裂应遵循整体考虑，联合远位组织，综合利用现有材料，留有后路的指导思想，联合应用口腔粘膜，阴股沟中厚皮片再造尿道或与邻位皮瓣组合的方法修复的成功率高，值得推广。     

口腔黏膜预植分期再造尿道修复复杂型尿道下裂

目的 探讨应用口腔黏膜预植对复杂型尿道下裂分期再造尿道的方法.方法 1999年1月至2003年3月对40例患者应用口腔黏膜预植再造尿道,采用两种术式：一是游离移植口腔黏膜于阴茎腹侧,半年后二期卷管修复尿道（Ⅰ式）,二是口腔黏膜卷管游离移植再造阴茎段部分尿道,半年后吻接两尿道（Ⅱ式）.结果 所有病例二期手术后愈合良好,无尿瘘发生,排尿通畅.结论 本术式为复杂型尿道下裂提供了一种可靠而有效的手术方法,有推广价值.     

颊粘膜移植修复尿道下裂的术后护理

目的 探讨应用颊粘膜移植加镍钛记忆合金尿道支架行一期尿道再造治疗尿道下裂的术后。 方法 对2004年10月至2006年10月33例应用颊粘膜移植加镍钛记忆合金尿道支架行尿道再造的尿道下裂患者的临床资料进行回顾性分析。术后进行细心的心理护理,密切观察术后不良反应并及时采取有效措施,加强术后康复护理。 结果 33例患者随访8月至18月,4例出现尿瘘、2例出现尿道狭窄,其中2例小尿瘘在经过保守治疗及护理下,于术后14～20天自行愈合。2例尿瘘及2例尿道狭窄分别在术后3个月及4个月再次手术成功。结论 应用颊粘膜移植加镍钛记忆合金尿道支架行尿道再造治疗尿道下裂,采取针对性且有效的术后护理措施,是手术成功的重要保证。     

游离空肠片移植修复食管癌术后颈部吻合口瘘

颈部吻合口瘘是食管癌行全胸段食管切除颈部食管胃吻合术后的常见并发症,复杂的吻合口瘘处理困难。自1985年以来,我院应用吻合血管的游离空肠片移植修复颈部吻合口瘘2例,效果良好,报道如下。     

包皮内板游离移植耦合包皮岛状瓣治疗阴茎型尿道下裂

目的探索一种新的尿道下裂手术方法。方法应用包皮内板游离移植，耦合包皮岛状皮瓣再造尿道冶疗阴茎型尿道下裂。结果2002年10月至2004年3月共治疗10例阴茎型尿道下裂患者，术后随访1年，效果满意，再造尿道形态逼真，无一例发生尿瘘、尿道狭窄等并发症。结论本法综合运用了皮片、皮瓣移植的优点，手术方法简单，成功率高，是一种较理想的阴茎型尿道下裂修复方法。     

尿道下裂术后尿道狭窄的预防及再手术术式选择

目的：探讨尿道下裂术后尿道狭窄的预防及再手术术式选择。方法：对53例尿道下裂术后尿道狭窄病例的临床资料进行回顾性分析。结果：53例中获访45例，其中尿道外口狭窄或闭锁行尿道外口成形12例，8例治愈；26例单纯吻合口狭窄行狭窄段剖开、切除吻合或一期尿道重建，17例治愈；新尿道全部瘢痕狭窄行广泛切除一期尿道重建4例，2例治愈；尿道造瘘二期尿道重建3例，2例治愈。结论：尿道狭窄是尿道下裂术后严重的并发症，关键在于预防，应根据不同的情况选择合理的治疗方法。     

空肠带蒂移植代食管术治疗颈段食管癌

目的报道带血管蒂游离空肠移植代食管术治疗颈段食管癌的临床效果。方法对颈段食管癌切除术后，应用显微外科技术行游离空肠移植颈部血管吻合重建食管。结果临床治疗11例，移植空肠全部成活，无1例发生缺血性坏死，随访6～12个月，无吻合口瘘及狭窄发生。结论空肠带蒂移植代食管治疗颈段食管癌，取材方便，手术安全、可靠。     

足趾移植再造拇指及手指541例

１９７７年～１９９６年共行足趾移植再造拇指及手指５４１例（６５４指），其中再造拇指４０４例，手指７８例（１２２指），拇指及手指同时再造５９例（１２８指）。拇指再造方式为：拇指Ⅰ、Ⅱ度缺损足趾移植４２例，口止母趾甲皮瓣加髂骨块移植１６例，Ⅲ、Ⅳ度缺损行口止母趾甲皮瓣与第二趾骨关节肌腱血管神经联合移植３４例，第二跖趾关节以远移植１８２例，Ⅴ、Ⅵ度缺损行携带跖趾关节的第二趾移植１８９例。手指再造为：手指Ⅱ、Ⅲ度缺损行趾与指吻合血管移植再造２９例，Ⅳ、Ⅴ度缺损再造８１例，Ⅵ度缺损再造２７例（共１９１指）。发现血管变异１０４例（１９．２％），其中足背动脉１９例，大隐静脉１３例，第一跖背动脉７２例。术后再造的拇指手指全部成活。对术前手术方案设计，手术要点，尤其是对血管变异的处理提出了行之有效的方法。     

吻合血管的拇指再造16例报告

目的:总结16例吻合血管的拇指再造的临床经验。方法:1997年2月～2001年8月对16例需行拇指再造患者应用吻合血管的游离(足母)趾甲皮瓣移植,游离第二足趾移植,示指弄位再植再造拇指。结果:16例再造拇指全面成活,手指外形、感觉、运动功能恢复满意。结论:吻合血管的显微拇指再造外形、感觉运动功能是拇指缺损患者修复再造的良好方法。     

采用空肠移植重建食管的血供保护

目的探讨游离移植空肠重建食管血供保护的有效措施。方法采用循证医学回顾性研究方法，分析了1980年～2001年采用游离空肠移植重建食管28例，带蒂空肠移植重建食管41例，其中因化学灼伤食管致瘢痕狭窄48例，食管癌切除术后21例的术式和移植肠管的血供保护措施。结果69例均获1～21年随访。1996年前施术43例，术后发生吻合口瘘5例，因暴饮暴食致移植空肠发生绞窄性梗阻坏死1例；1996年以后施术26例，其中游离空肠移植重建食管6例，带蒂空肠移植重建食管20例，仅1例发生吻合口瘘。全组无手术死亡。结论保证空肠段和吻合口充分血供的有效措施为：①空肠段边缘血管弓完整、无张力、供血充分；②吻合口血管通畅；③空肠段上提通道宽畅；④保持围术期稳定的动脉压(8kPa以上)；⑤采用全层缝合术；⑥采取综合性保护措施，改善患者全身营养代谢状况。     

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。     

应用口腔黏膜再造尿道远期观察研究

目的观察口腔黏膜再造尿道的远期外观与结构变化,以及与正常尿道黏膜的差异。明确口腔黏膜用作再造尿道材料的优缺点,以及与尿道下裂术后并发症是否有相关性。探讨用口腔黏膜作再造尿道材料的可行性。方法随访应用口腔黏膜再造尿道患者的远期形态与功能。应用尿道镜观察应用口腔黏膜再造尿道的远期外观。应用光学显微镜观察取自口腔黏膜再造尿道内壁的标本,同时对比观察正常口腔黏膜和尿道黏膜标本。结果应用口腔黏膜再造尿道,远期外形良好,排尿功能正常。再造尿道壁大体外观接近正常,但组织结构仍为典型口腔黏膜。结论应用口腔黏膜再造尿道,远期形态、功能均接近正常尿道,但组织结构没有改变。口腔黏膜是良好的再造尿道组织材料。     

A New Option for the Management of Urethral Trauma: Primary Reconstruction of Posterior Urethral Disruption with a Buccal Mucosa Transplant

Up to now, the management of traumatic posterior urethral disruption ranges from primary realignment to delayed urethroplasty. However, we reconstructed the membranous part of the urethra with an onlay graft of buccal mucosa after traumatic complete disruption as a first line therapy. After 7 months followup, the clinical outcome is very good. Because primary reconstruction of the urethra with a buccal mucosa graft after traumatic disruption has not yet been reported, the question arises whether this technique should be routinely included as an option for primary urethral reconstruction after trauma of the posterior urethra.     

CONSTRUCTION OF FEMALE URETHRA USING BUCCAL MUCOSA GRAFT

PURPOSE: We reviewed our experience with buccal mucosa grafts for reconstructing difficult female urethral problems. METHODS AND METHODS: Since 1994, we have used a buccal mucosa graft to reconstruct the urethra in 7 girls 3 to 13 years old. The underlying pathological condition was a fibrotic urethra after previous operations for cloacal exstrophy, cloacal malformation, iatrogenic urethral stricture, and multiple false passages in a previously reconstructed urethra of vaginal mucosa that made clean intermittent catheterization difficult. A full-thickness buccal mucosa graft was tubularized in situ as the neourethra to the base of the clitoris. In patients with cloacal exstrophy and cloacal malformation the bladder neck and urethra were widely exposed transabdominally by splitting the pubic symphysis. The fibrotic mucosa was excised and the tubularized buccal mucosa graft was wrapped with periurethral tissues. Other patients underwent transvaginal surgery in the prone position and the graft was covered with a buttock flap. RESULTS: Patients were followed for 12 to 58 months (mean 34.7). Those with cloacal exstrophy and cloacal malformation had been completely incontinent before urethral reconstruction but all attained complete continence postoperatively. They and the girl who underwent urethral reconstruction for difficult catheterization performed clean intermittent catheterization easily. The patient with urethral stricture voided via the urethra without difficulty. CONCLUSIONS: In select female patients with difficult urethral reconstructive problems a tubularized free graft obtained from the buccal mucosa may be effectively used when local tissue is fibrotic and unsuitable for creating a supple new urethra.     

One-stage circumferential buccal mucosa graft urethroplasty for bulbous stricture repair

A one-stage onlay urethroplasty, using a buccal mucosa graft, is presented for patients with bulbous strictures in whom the urethral mucosa is seriously involved in the disease. Of 40 patients who underwent a dorsal buccal mucosa graft urethroplasty for bulbous urethral strictures, 5 required complete removal of the urethral mucosa and its replacement by a buccal mucosa graft. All these patients had undergone previous urethrotomy with a false passage inside the bulbous urethra and had a suprapubic tube in place. The goal of removal and replacement of the urethral mucosa in each case was to create a new, wide urethral mucosal bed to promote successful one-stage reconstruction. All patients voided spontaneously without problems after removal of the catheter. After 4 months, the mean peak flow was 21 mL/s. After 6 months, urethroscopy did not show any stricture recurrence. None of the patients required instrumentation or dilation. In patients with bulbous urethral strictures and false passage into the mucosa and spongiosum tissues, the complete removal and replacement of the urethral mucosa using a circumferential buccal mucosa graft promotes successful one-stage urethral reconstruction.     

不同组织材料再造尿道的远期对比观察

目的 对比应用不同组织材料再造尿道内壁的远期外观和组织结构变化及与正常尿道的区别,遴选用于再造尿道的组织材料.方法 术中直视或应用尿道造影、尿道镜观察再造尿道内壁外观.应用光镜、电镜观察再造尿道切片组织结构.结果 应用皮肤或黏膜再造尿道远期外观均接近正常尿道,远期组织结构也未见改变;应用口腔黏膜再造的尿道,远期组织结构还具备形成正常尿道微环境的一些重要结构基础;应用膀胱黏膜者,远期组织结构接近正常尿道.结论 膀胱黏膜和口腔黏膜可能是较皮肤更适用于再造尿道的组织材料.     

颊黏膜尿道成形术治疗前尿道狭窄的临床分析

目的 探讨利用游离口腔颊黏膜尿道成形术治疗前尿道狭窄的疗效.方法 2011年6月至2012年12月采用颊黏膜腹侧扩大替代尿道成形术治疗25例前尿道狭窄,狭窄段长度为3.5～10 cm,平均5.74 cm.术前耻骨上膀胱造瘘16例,余9例术前最大尿流率2.4～7.6 mL/s,平均4.3 mL/s.结果 术后随访3～18个月,平均6.5个月.术后患者排尿通畅22例(88％),尿动力学检查显示最大尿流率为14～28mL/s,平均19.4 mL/s.3例(12％)吻合口处狭窄,经历尿道扩张后,排尿通畅.所有患者均无感染及尿道皮肤瘘发生,口腔颊黏膜移植物均成活.结论 口腔颊黏膜可作为较理想的尿道替代物,适合长段或多段狭窄的尿道修复.     

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.     

颊粘膜预制尿道分期治疗尿道下裂残废

目的：探讨运用颊粘膜移植预制尿道,分期治疗尿道下裂残废。方法：2001年至今,对76例尿道下裂残废患者采用Ⅰ期颊粘膜移植预制远端尿道,Ⅱ期局部皮瓣转移尿道吻接的方法进行手术治疗。结果：术后除一例尿道口狭窄外,其余病例的尿道均通畅,疗效满意。结论：颊粘膜移植分期尿道成形术是治疗尿道下裂残废的有效方法之一。     

Combined Dorsal and Ventral Buccal Mucosal Graft Urethroplasty by Unilateral Mobilisation of Urethra with Single Dorsal Urethrotomy Incision in Long Segment Anterior Urethral Strictures

The aim of this study is to evaluate the outcomes of combined dorsal and ventral buccal mucosal graft urethroplasty by unilateral mobilisation of urethra with single dorsal urethrotomy incision in long and narrow anterior urethral strictures with preserving the narrow urethral plate and blood supply. Between June 2012 and July 2016, 26 men with long anterior urethral strictures underwent urethroplasty by our technique in a tertiary care teaching hospital. The urethra was mobilised only one side. Then, it was opened in the dorsal midline over the stricture. The first graft was secured on the tunica of the corporal bodies. Thereafter, the diseased mucosa on the ventral side of the urethra was excised and the second graft was placed as ventral inlay and fixed to the corpus spongiosum. The cut edges of urethra were closed by suturing to dorsally placed graft. Successful urethral reconstruction was defined as normal voiding without the need for any postoperative procedure. Mean follow-up was 36 months and mean stricture length was 4.29 cm. Of these 26 cases, 23 (88.4%) were successful and 3 (11.53%) were treatment failures with restricture. The combined dorsal plus ventral buccal mucosal graft urethroplasty by unilateral mobilisation of urethra with single dorsal urethrotomy incision provides adequate urethral augmentation by preserving urethral vascularity and the narrow strip of urethral plate in long and tight anterior urethral strictures.