骨盆骨折合并后尿道损伤后阳萎发生机理的临床研究

为探讨骨盆骨折后尿道损伤后发生阳萎的机理、收集５１例骨盆骨折、后尿道损伤后患者的资料，对其性功能状况进行随访，并对１０例阳萎患者进行了有关阴茎勃起功能的检查。结果表明：伤后阳萎是初期损伤和（或）手术损伤所造成的阴茎神经、动脉损伤所致。由于解剖上的原因，单纯早期损伤所致阳萎多为神经性阳萎，而手术损伤多为动脉性阳萎。此外，损伤程度、伤时年龄及伤后时间等因素与阳萎的发病也有一定的关系。     

经会阴尿道吻合术治疗小儿外伤性后尿道狭窄闭锁

目的 评价小儿外伤性后尿道狭窄闭锁的处理方法及远期疗效。方法 对１６例尿道狭窄及闭锁患儿行经会阴道尿道吻合术１９例次，随访２～２１年，观察排尿，控尿及性功能情况。结果 １６例患儿中１５例正常排尿，１例需定期尿道扩张，术后发生尿失禁４例（２５．０％），阳萎３例（１８．０％），４例尿失禁患儿随年龄增长症状有不同程度改善，３例阳萎病人病情无变化。结论 对外伤性后尿道狭窄闭锁的患儿，伤后６个月，首选经会阴     

骨盆骨折合并尿道断裂的早期手术治疗

目的探讨骨盆骨折合并尿道断裂的早期手术方法及其治疗效果。方法自1995年1月至2005年1月,共收治骨盆骨折合并尿道断裂患者25例。根据Tile的分型方法,骨盆稳定型损伤1例,旋转不稳定型损伤17例,旋转及垂直均不稳定型损伤7例。尿道完全断裂23例、部分断裂2例。手术方法包括：（1）急诊尿道吻合、尿道会师部分吻合、尿道会师、尿道阴道贯通伤修补,同期行骨盆骨折开放复位内固定术9例。（2）急诊尿道会师,延期（7—21d）行骨盆骨折切开复位内固定术10例。（3）急诊膀胱造瘘,限期（3～21d）行尿道会师及骨盆骨折切开复位内固定术6例。结果术后随访6～120个月,平均34个月。骨盆损伤根据Majeed的疗效标准,优17例,良5例,可3例。尿管拔除后,19例（76％）患者排尿通畅,最大尿流率平均为18．6mL／s,排泄性尿路造影示尿道断端对位良好,瘢痕平均长度为0．51cm;5例（20％）出现不同程度的排尿困难,须定期扩张尿道或改行其他手术;1例（4％）女性患者不能控制排尿,须进一步治疗。术后耻骨上原发软组织撕脱伤感染伴耻骨后脓肿形成1例,后尿道狭窄5例,阳痿3例,尿失禁1例。结论骨盆骨折的早期复位和有效固定是实现“无张力尿道修复”的解剖基础。     

尿道损伤的X线分类及临床应用

目的：评价尿道造影对尿道损伤分类及处理的价值。方法：对４０例尿道损伤患者进行尿道造影及临床分类，并按其分类进行相应的处理。结果：行腔内处理及开放手术２５例（Ⅱ～Ⅳ）类，其尿道造影分类与手术所见对照，诊断符合率为１００％。３６例按临床分类治疗者中仅１例发生尿道狭窄，治愈率为９７．２％。４例未按临床分类治疗者均发生尿道狭窄。结论：尿道造影对尿道损伤临床分类是一个无创、可靠的诊断方法。按此临床分类进行治     

薄壁金属管治疗后尿道闭锁及严重狭窄

我科1994～1996年间采用薄壁金属管治疗后尿道闭锁及严重狭窄16例，疗效满意，现报告如下。1资料与方法1．1临床资料本组16例，年龄3～65岁，平均32岁。其中骨盆骨折引起尿道完全闭锁10例、严重狭窄z例，骨盆骨折损伤尿道后经手术修补后再闭锁和扩张形成假道各1例，时间为6～48个月，平均25个月，经膀眈前列腺切除后3～6个月尿道严重狭窄2例。所有患者术前均行尿道及膀航造影。骨盆骨折引起者均发生在膜部，长度为0．4～1．2cm（平均0．scm），1例证实有假道，2例前列腺术后尿道严重狭窄者中1例为后尿道摄痕狭窄，1例为出口部梗阻。本组患者…     

经会阴途径后尿道端端吻合术治疗创伤性后尿道狭窄十年回顾性研究

目的：评估各种尿道修复术式在不同程度后尿道狭窄中的运用及治疗效果。方法：从1997年1月～2006年12月共有296例外伤性骨盆骨折导致的后尿道狭窄患者接受后尿道端端吻合术,其中单纯端端吻合70例（Ⅰ组）;阴茎海绵体中隔切开结合端端吻合70例（Ⅱ组）;海绵体中隔＋耻骨下缘切除结合端端吻合154例（Ⅲ组）;耻骨下缘切除＋尿道从一侧阴茎海绵体旁绕结合端端吻合2例（Ⅳ组）。结果：296例后尿道端端吻合术中,254例成功,42例失败。Ⅰ组成功率78．6％,Ⅱ组成功率90．0％,Ⅲ组成功率88．3％,Ⅳ组成功率为0。结论：经会阴途径的不同辅助手术方法可有效地治疗后尿道狭窄。     

骨盆骨折后尿道断裂的早期处理

目的 总结骨盆骨折后尿道断裂的诊治经验。方法 对15例骨盆骨折后尿道断裂患者的临床资料、早期处理、治疗结果进行回顾性分析。结果 15例骨盆骨折后尿道断裂患者13例在6周左右痊愈，2例仅需短期尿道扩张痊愈。一次治愈率86．7％。无阳萎及尿失禁。结论 尿道会师加膀胱颈口会阴牵引复位术是治疗骨盆骨折后尿道断裂的一种行之有效的方法，且能减少术后并发症的发生。     

尿道置三根硅胶管治疗骨盆骨折后尿道断裂及炎性尿道狭窄

为改进探讨骨盆骨折后尿道断裂、炎性尿道狭窄新的治疗方法,作者对骨盆骨折后尿道断裂会师术后７～１０天患者６６例、炎性尿道狭窄患者１５例强行扩张术后,尿道内置三根２．５ｍｍ硅胶管,留置３个月。结果：骨盆骨折后尿道断裂６６例,治愈率８７．９％,良好率３．０％,失败率９．１％;炎性尿道狭窄１５例,全部治愈。本组８１例总治愈率９２．６％,失败率７．４％。作者认为,该术式操作简单、安全、有效,并且能显著地降低尿道感染及狭窄。     

外伤性尿道损伤的诊治体会

骨盆骨折合并后尿道损伤是男性泌尿外科常见急症,其早期并发症如尿失禁、阳萎,远期并发症尿道狭窄,除与骨盆骨折尿道损伤程度有关外,还与急诊处理措施是否恰当、及时有很大关系。本组收集1976年～1996     

小儿外伤性后尿道损伤急症处理与远期疗效观察

为了评价小儿外伤性后尿道损伤急症处理方法的效果，将１９例后尿道损伤患儿分为尿道会师组和单纯膀胱造瘘组，对二组的急诊处理方法及远期疗效进行了回顾性分析。结果：尿道会师组术后７５％出现尿道狭窄，单纯膀胱造瘘组为１００％，长期随访发现二组阳萎和尿失禁发生率之间无显著性差异。结论：（１）小儿后尿道损伤急症处理方法的选择应根据患儿全身情况，尿道损伤部位，断端移位情况等决定；（２）同单纯膀胱造瘘术相比，不加牵引的尿道会师术并不增加远期阳萎和尿失禁的发生率     

Voiding and sexual dysfunctions after pelvic fracture urethral injuries treated with either initial cystostomy and delayed urethroplasty or immediate primary urethral realignment.

OBJECTIVE: The aim of this study is to evaluate the effects of the different immediate treatment modalities on the sexual and voiding functions in pelvic fracture urethral injuries. METHODS: The records of 38 male patients with traumatic posterior urethral injuries were reviewed, 18 of whom were treated by initial suprapubic cystostomy and delayed repair (Group 1), and 20 by primary urethral realignment (Group 2). Types of pelvic fractures and urethral injuries were classified according to surgical and radiological findings. Long-term voiding functions were determined by the patient questionnaire, residual urine and uroflow. Sexual functions were also determined by the patient questionnaire and a penile duplex ultrasound study. RESULTS: Mean follow-ups of Groups 1 and 2 were 37 and 39 months, respectively. Membranous urethral disruption extending to the urogenital diaphragm was the most frequent urethral injury (type 3), with incidences of 66.7% and 77.7%, respectively. There were no statistically significant differences in mean age, incidence of pelvic fracture types and urethral injury types between groups (p > 0.05). After the immediate treatments, 16.7% and 55% of the patients regained normal urination, and stricture developed in 83.3% and 45% of the patients, respectively. In 44.4% of the patients in Group 1 and 10% in Group 2, urethral strictures required open urethroplasty (p < 0.05). Erectile impotence before urethroplasty in 17.6% and 20%, anejaculation after urethroplasty in 17.6% and 15% and incontinence in 5.6% and 10% of the patients were found in Groups 1 and 2, respectively (p > 0.05). However, 88.8% and 90% of patients eventually achieved normal urination with complete continence. CONCLUSION: Sexual and voiding dysfunction after pelvic fracture posterior urethral injury seem to be the result of the injury itself, not of the immediate treatment modalities. In urethral disruption injuries, primary urethral realignment seems more favourable than suprapubic cystostomy and delayed repair.     

Endoscopic treatment of complete posterior urethral obliteration

The management of posterior urethral obliteration remains a surgical challenge. We report our experience with 5 patients treated endoscopically for posterior urethral obliteration. We performed endoscopic reconstitution of the urethra followed by temporary self-dilation in five patients with complete short posterior urethral obliteration (less than 3 cm). Average follow-up is 31 months (21-53 months). During follow-up 4 of these patients required 1 or 2 internal urethrotomies within the first 4 to 24 months after treatment. But, any urethral stricture has not been established until the average 23.2 months (21 to 27 months). The other fifth patient has no complication at twenty-first month postoperatively. One patient had impotence after the injury. Impotence continued and total incontinence developed after the endoscopic treatment. We believe that endoscopic treatment followed by temporary self-dilation could be a reasonable alternative to open urethroplasty in patients with an impassable short stricture.     

Complex posterior urethral disruptions: management by combined abdominal transpubic perineal urethroplasty

PURPOSE: We present our short-term results of abdominal transpubic perineal urethroplasty for complex posterior urethral disruption. MATERIALS AND METHODS: From January 2000 to March 2005, 21 patients with complex posterior urethral disruption underwent abdominal transpubic perineal urethroplasty. Complex disruption was defined as stricture gap exceeding 3 cm or associated perineal fistulas, rectourethral fistulas, periurethral cavities, false passages, an open bladder neck or previous failed repair. Preoperative voiding cystourethrogram with retrograde urethrogram and cystourethroscopy were done to evaluate the stricture and bladder neck. Followup consisted of symptomatic assessment and voiding cystourethrogram. RESULTS: There were 11 adults and 10 prepubescent boys with an average age of 26 years (range 6 to 62). Mean followup +/- SD was 28 months (range 9 to 40). Mean stricture length was 5.2 +/- 1.4 cm. Of the 21 patients 12 had previously undergone failed urethroplasty. The mean period between original trauma/failed repair and definitive repair was 10.2 +/- 4.3 months. Urethroplasty was achieved through the subpubic route in 16 patients, while 5 required supracrural rerouting. In 20 of 21 patients (95%) postoperative cystourethrography showed a wide, patent anastomosis. Postoperative incontinence developed in 2 of 21 patients (9.5%). Seven of the 21 patients (33%) were impotent after the primary injury, while 3 of 14 (21.4%) had impotence postoperatively. There were no complications related to pubic resection, bowel herniation or periurethral cavity recurrence. CONCLUSIONS: Combined abdominal transpubic perineal urethroplasty is a safe procedure in children and adults. It allows wide exposure to create a tension-free urethral anastomosis without significantly affecting continence or potency. Complications of pubic resection are now rarely seen.     

弧形导针后尿道吻合术治疗疤痕性后尿道狭窄228例

目的：总结陈旧性后尿道狭窄治疗方法。方法：陈旧性后尿道狭窄或闭锁患228例，应用弧形导针、专用缝线行经会阴一个径路切除后尿道疤痕组织，尿道断端横褥式外翻缝合。结果：一次性手术治愈202例，成功率88％。术后随访0．5—16a 188例，偶需尿道扩张20例，术后出现不同程度的阳痿78例(34％)。结论：弧形导针后尿道吻合术有较高的成功率和满意的治疗效果。操作简单，损伤小，值得推广。     

Experience with management of posterior urethral injury associated with pelvic fracture

Review of records from 205 patients with pelvic fracture and hematuria revealed that 121 underwent urologic and radiographic evaluation. Of these patients 20 had severe posterior urethral injuries documented by urethrography of voiding cystourethrography: 9 underwent primary repair and 11 had delayed scrotal-inlay urethroplasty after initial cystostomy alone. Patients who underwent primary repair had a 77 per cent incidence of stricture, a 22 per cent incidence of incontinence and a 33 per cent incidence of impotency. Patients who underwent delayed closure had no incidence of stricture, incontinence or impotence. Patients in both groups had urinary tract infections. Simple cystostomy followed by delayed scrotal-inlay urethroplasty appears superior to primary realignment in the management of patients with posterior urethral injuries.     

An unusual complication of penile prosthesis following urethroplasty

We report a case of an adult who had undergone transpubic urethroplasty for a 5-cm long posterior urethral stricture. A malleable penile prosthesis (AMS 600R) was implanted 19 months later for the trauma-related impotence. The patient was discovered to develop a complete obliteration of the urethra after removal of infected penile prosthesis 18 months later. Perineal urethroplasty cured his restricture. Suggestions are made to prevent urethral restricture if penile prosthesis is required after urethroplasty.     

Posterior urethral reconstruction

Summary The posterior prostatomembranous urethral stricture or distraction defect has historically been the most formidable challenge of stricture surgery. This uncommon lesion occurs most often as the sequelae of pelvic fracture injuries, or straddle trauma, and is associated with serious urethral disruption and separation – an injury that is often complicted by inappropriate initial management using substitution skin flap techniques with the development of recurrent stenosis, irreversible impotence, and occasional incontinence. Management by endoscopic techniques may be possible in patients with short strictures or in those after prostatectomy, but they rarely play a role in resolving the complex obliterated urethra with a significant defect [1]. Resolution of post-traumatic posterior urethral distraction defects and other posterior urethral pathologic conditions has dramatically improved over the past two decades despite an inaccessible subpublic location involving exposed sphincter-active and erectile neurovascular anatomy. The contemporary, perineal, one-stage bulboprostatic anastomotic operation as popularized by Turner-Warwick [20] with selective scar excision is a versatile procedure with a high patent lumen success. Patients undergoing anastomotic urethroplasty have a substained patent urethral lumen success rate approaching 100 % versus those who have undergone urethral skin flap or patch repair, where the restricture rate in 5 and 10 years increases twofold to threefold [1, 20]. A patent urethra after an anastomotic urethroplasty at 6 months is free from further recurrent stricture and gives credence to Mr. Turner-Warwick's admonition that “urethra is the best substitute for urethra”.      

尿道重建治疗男性尿道狭窄对勃起功能、性生活质量的影响

目的:探讨男性尿道狭窄手术对勃起功能以及性生活质量的影响因素。方法:回顾性分析326例行尿道重建手术男性患者的临床资料,并进行随访,分析年龄、尿道狭窄部位、长度、手术方式、手术次数、狭窄复发对术后勃起功能及性生活质量的影响。结果:共收集172例患者(52.8%)有效数据,平均随访时间28.5个月。手术后勃起功能(P=0.002)、性生活质量评分(P=0.026)较术前明显下降。术前56例(32.6%)患ED,术后88例患ED(51.2%),增加18.6%;术前勃起功能正常116例中有38例(32.8%)术后出现ED。结论:尿道狭窄部位、手术方式、术后尿道狭窄复发会降低尿道重建术后患者勃起功能、性生活质量。后尿道狭窄、采用经会阴途径尿道吻合患者术后ED发生率更大。勃起功能、性生活质量随着时间增长而逐渐改善。     

尿道端端吻合术后狭窄复发的危险因素分析

目的分析尿道狭窄患者行尿道端端吻合术(excision and primary anastomotic urethroplasty,EPA)后狭窄复发的危险因素。方法回顾性分析2017年1月至2018年12月上海交通大学附属第六人民医院收治的209例尿道狭窄患者的临床资料。年龄42.1(5~78)岁。肥胖(体质指数>28 kg/m2)25例(12.0%)。既往有糖尿病史12例(5.7%),术前3个月吸烟史103例(49.3%)。术前未行尿道扩张127例(60.8%),尿道扩张1~2次42例(20.1%),尿道扩张≥3次40例(19.1%)。术前有尿道内切开术史56例(26.8%)。术前无尿道成形术史157例(75.1%),尿道成形术1次38例(18.2%),尿道成形术≥2次14例(6.7%)。术前行膀胱造瘘201例(96.2%),未行膀胱造瘘8例(3.8%)。后尿道狭窄183例,球部尿道狭窄26例。狭窄时间35.1(1~360)个月。狭窄段长度(3.19±0.65)cm。病因为外伤190例,医源性损伤12例,炎性狭窄2例,其他5例。患者均行EPA治疗,69例(33.0%)术中行耻骨下缘切除。术后复发标准:拔除导尿管后出现排尿困难,经尿道镜或尿道造影检查提示手术部位尿道狭窄。对可能导致狭窄复发的因素采用Cox比例风险回归模型进行单因素和多因素分析。结果本组209例术后随访18.8(3~32)个月。31例(14.8%)出现狭窄复发,复发时间(5.3±5.6)个月。单因素分析结果显示,狭窄时间(HR=1.007,P<0.001),狭窄段长度(HR=5.334,P<0.001),尿道内切开术史(HR=2.901,P=0.003),尿道扩张≥3次(HR=6.214,P<0.001),尿道成形术1次、≥2次(HR=4.175,P=0.001、HR=9.885,P<0.001),术前3个月吸烟史(HR=2.605,P=0.016),膀胱造瘘(HR=0.231,P=0.006),耻骨下缘切除(HR=6.603,P<0.001)与狭窄复发有相关性。多因素分析结果显示狭窄段长度(HR=4.911,P<0.001),尿道成形术1次、≥2次(HR=2.387,P=0.045、HR=3.688,P=0.015),术前3个月吸烟史(HR=2.730,P=0.030)是狭窄复发的独立危险因素。结论EPA术后尿道狭窄复发多集中在术后6个月内,患者尿道狭段窄长度、尿道成形术史、术前3个月吸烟史是狭窄复发的独立危险因素。     

ERECTILE FUNCTION AFTER ANTERIOR URETHROPLASTY

PURPOSE: We ascertained the impact of anterior urethroplasty on male sexual function. MATERIALS AND METHODS: A validated questionnaire was mailed to 200 men who underwent anterior urethroplasty to evaluate postoperative sexual function. Questions addressed the change in erect penile length and angle, patient satisfaction with erection, preoperative and postoperative coital frequency, and change in erection noted by the sexual partner. Results were stratified by the urethral reconstruction method, namely anastomosis, buccal mucosal graft, penile flap and all others, and compared with those in a similar group of men who underwent circumcision only. RESULTS: Of the 200 men who underwent urethroplasty 152 who were 17 to 83 years old (mean age 45.7) completed the questionnaire. Average followup was 36 months (range 3 to 149). Overall there was a similar incidence of sexual problems after urethroplasty and circumcision. Penile skin flap urethroplasty was associated with a slightly higher incidence of impaired sexual function than other procedures (p >0.05). Men with a longer stricture were most likely to report major changes in erectile function and penile length (p <0.05) but improvement was evident with time in 61.8%. CONCLUSIONS: Overall anterior urethral reconstruction appears no more likely to cause long-term postoperative sexual dysfunction than circumcision. Men with a long stricture may be at increased risk for transient erectile changes.