尿道、阴茎

20061582 逆行复合尿道板皮瓣联合阴囊瓦合皮瓣尿道成形修复重度尿道下裂／易传勋…∥临床泌尿外科杂志．-2005.20（10）．-590～592 应用逆行复合尿道板皮瓣联合阴囊瓦合皮瓣尿道成形修复重度尿道尿道下裂患者。结果：手术获得成功。术后12d拔除导尿管白行排尿，无尿瘘和尿道狭窄发生。结论；逆行复合尿道板皮瓣血运丰富，伸延性好，手术操作简单，联合阴囊瓦合皮瓣尿道成形术可一期完成尿道下裂修复。成形效果好，是一期修复重度尿道下裂的比较理想的术式。图2参10     

先天性阴茎弯曲的手术矫治

目的:通过几种常用的手术方法来探讨先天性阴茎弯曲的治疗效果。方法:2002年3月~2005年2月共治疗先天性阴茎弯曲76例,其中合并尿道下裂67例、尿道上裂5例和尿道开口正常4例。治疗方法包括术前5周绒毛膜促性腺激素治疗、术中阴茎皮肤彻底脱套、尿道周围异常分布纤维索带完全松解、阴茎腹侧或背侧白膜折叠、白膜切开全厚游离皮瓣或睾丸鞘膜嵌入等手术。结果:术后随访2个月~2年,平均9.3个月。88%(67例)获得完全矫正;8%(6例)尚遗留轻度弯曲,暂无需再次手术,但需远期观察;另有4%(3例)虽手术中阴茎弯曲已明显纠正,但术后出现复发,需再次手术。结论:通过上述几种治疗方法,绝大多数先天性阴茎弯曲可以得到充分矫正。     

手术治疗阴茎结节性海绵体炎和先天性阴茎弯曲

采用Ｎｅｓｂｉｔ法和单纯缝扎术对３５例阴茎弯曲患者（Ｐｅｙｒｏｍｉｅ病１４例，先天性阴茎弯曲２１例）手术矫正。就手术并发症，术后复发和性交能力对两种手术进行比较。手术并发症均经及时，不影响手术效果（除１例术后阴茎过短无法性交外）。术后复发９例，其中８例为单纯缝扎术后（ｎ＝２４），１例为Ｎｅｓｂｉｔ法术后（ｎ＝１１）。手术矫正效果和术后性交能力以Ｎｅｓｂｉｔ法优于单纯缝扎法。     

尿道、阴茎

20060786术中输尿管镜检查在诊断会阴型尿道下裂并发前列腺囊的应用,20060787保留尿道板一期尿道成形治疗尿道下裂,20060788小儿尿道损伤的诊断与治疗，20060789可冲洗尿道的导尿管预防留置尿管所致逆行尿路感染的研究，20060790新型KTP／S32激光在尿道闭锁治疗中的应用，20060791膀胱粘膜尿道成形术治疗复杂性尿道下裂。[编者按]     

先天性尿道短缩症的治疗

目的：探讨尿道短缩症（又称隐匿型尿道下裂）的治疗方法。方法：自1982年11月－2000年12月收治先天性尿道短缩症18例，分别采用：①尿道延伸术，②带血管蒂的横行包皮内板皮瓣尿道成形术，③带血管蒂的纵行阴茎包皮皮瓣尿道成形术，④阴囊纵隔血管蒂皮瓣尿道成形术进行治疗。结果：17例一次手术治愈；采用第二种手术方法者有1例发生尿瘘，经二次手术治愈。结论：尿道短缩症应采用组织移植法延长尿道、修复周围组织，不同的类型需要采用不同的治疗方法。     

尿道、阴茎

复发性尿道狭窄伴假道的分类与处理；膀胱镜下尿道会师术治疗球部尿道损伤；8例骑跨伤致球部尿道断裂急诊手术治疗体会；Duckett术治疗尿道下裂17例疗效观察；保留尿道板的尿道下裂Ⅰ期成形术（附46例报告）；尿道下裂患者手术前后的尿道细菌分布；三角帆状阴茎皮瓣覆盖在尿道下裂修复术中的应用；斜行包皮岛状皮瓣尿道成形术治疗尿道下裂；纵行岛状包皮瓣尿道成形术矫正先天性短尿道畸形     

尿道、阴茎

腹股沟岛状皮瓣联合阴囊皮瓣修复耻骨部及阴茎瘢痕挛缩畸形；全露型包皮中触觉小体观察；镶嵌式唇黏膜瓣尿道成形术治疗前尿道狭窄；骨盆骨折合并尿道断裂的早期手术治疗；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     

尿道、阴茎

阴茎两侧肉膜蒂组织双层覆盖在Snodgrass尿道下裂修复中的应用,不同年龄包茎和包皮过长患者包皮组织中触觉小体的观察,腔内手术治疗后尿道狭窄与闭锁（附46例报告）,后尿道狭窄外科治疗191例临床分析,阴茎起勃器植入手术治疗阴茎硬结症合并重度S型弯曲（1例并文献复习）[编者按]     

阴茎弯曲的治疗(附20例报告)

目的:提高对阴茎弯曲的诊断及外科治疗水平。方法:回顾性分析20例阴茎弯曲矫形术及术后并发症,其中15例为先天性阴茎弯曲类型,采用阴茎皮肤袖状脱套+可吸收缝线单纯阴茎白膜折叠术矫形弯曲;5例为继发性阴茎弯曲患者,采用斑块切除+膀胱黏膜补片矫正阴茎弯曲。结果:20例术后随访6～24个月,平均18个月,无血肿,感染,尿瘘,阴茎感觉改变,勃起疼痛及勃起功能障碍等并发症,术后矫正率90%,2例术后矫正阴茎稍弯曲<15°,1例术后阴茎缩短约2cm。结论:根据阴茎弯曲的程度,选择合理的手术方式,可矫正阴茎弯曲,保证有效的勃起功能及一定的阴茎长度。     

Corporeal plication for the treatment of congenital penile curvature

PURPOSE: We evaluated the long-term outcome, effectiveness and patient satisfaction of corporeal plication for the correction of congenital penile curvature. MATERIALS AND METHODS: A total of 25 patients with congenital penile curvature were included in the study. Mean age was 39 years (range 15 to 45). Patients with Peyronie's disease, and/or chordee associated with hypospadias or evidence of erectile dysfunction were excluded from analysis. All procedures were done on an outpatient basis using local anesthesia. The technique of corporeal plication consists of placing longitudinal plication sutures of 2-zero braided polyester on the opposing side of curvature until it is corrected during artificially induced erection. A standardized questionnaire was then completed via telephone interview to assess results as well as the patient satisfaction rate. RESULTS: A total of 22 patients were available for evaluation. Successful results at up to 3(1/2) years (range 1 to 42 months, mean 18) of followup were achieved in 21 of the 22 patients (95%). Success was defined as the correction of curvature and a patient satisfaction rate of 75% or greater. Curvature was ventral in 20 cases, dorsal in 2 and left lateral in 3. Shortening of the penis after surgery was noted by 4 patients (18%), of whom 3 nevertheless had a satisfaction rate of 75% or greater. In 2 patients postoperative hematoma resolved spontaneously. Mean operative time was 50 minutes and 22 of the 25 patients (88%) received local anesthesia. CONCLUSIONS: Corporeal plication is a simple, minimally invasive surgical procedure that proved to be effective for congenital curvature of the penis compared with other, more extensive penile reconstruction surgery.     

Preservation of the thin distal urethra in hypospadias repair

PURPOSE: We report our experience with preserving the thin distal urethra lacking corpus spongiosum for the treatment of hypospadias. MATERIALS AND METHODS: From January 1997 to October 1999 we treated primary hypospadias in 77 boys with a mean age of 4 years 10 months. After degloving the penile skin a segment of thin distal urethra lacking corpus spongiosum was noted in 18 patients (23.4%) with a mean age of 3 years 5 months. The thin distal urethra was preserved and incorporated as part of urethroplasty (group 1). The procedure was primarily completed by tubularized incised plate urethroplasty. We also performed tubularized incised plate urethroplasty in 31 boys (40.3%) with a mean age of 5 years 2 months who had normal coverage of the corpus spongiosum of a hypospadiac urethra (group 2). We compared the results of treatment in these 2 groups. The remaining 28 patients (36.4%) treated with other methods were excluded from study. RESULTS: In group 1 the distance from the original meatus to the urethra covered by healthy corpus spongiosum was 4 to 20 mm. (mean 8.2). If the thin distal urethra had been excised, the urethral meatus would have been relocated more proximal in these boys. Mean followup in groups 1 and 2 was 9.9 and 7.6 months, respectively. Postoperatively there were 2 (11.1%) urethrocutaneous fistulas in group 1 and 4 (12.9%) in group 2. Tubularized incised plate repair was successful in all 10 cases (100%) of distal hypospadias in group 2, and in 15 of 18 (83.3%) and 17 of 21 (81%) of proximal hypospadias cases in groups 1 and 2, respectively. There was no statistically significant difference in the success rate of hypospadias repair in the groups. CONCLUSIONS: We noted a significantly thin distal urethra in 23.4% of our cases of primary hypospadias. Mean length of the thin distal urethra was 8.2 mm. Preserving the thin distal urethra may simplify the operative procedure without compromising the surgical results of tubularized incised plate urethroplasty.     

Phalloplasty and urethroplasty in children with penile agenesis: preliminary report

PURPOSE: Female gender has been assigned to 46,XY newborns affected by aphallia, possibly resulting in subsequent gender dysphoria. Prenatal and postnatal effects of the androgens on the brain and sexual orientation cannot be modified later. Therefore, patients affected by aphallia should be raised as males. Because definitive forearm flap phalloplasty is generally not recommended before puberty, we performed a preliminary penile reconstruction during childhood in 4 patients. MATERIALS AND METHODS: Four patients with aphallia who had no sex reassignment at birth were treated at age 9, 17 and 36 months, and 12 years in a single operation. The urethral channel was dissected through an anterior-sagittal-transanorectal approach, and then phalloplasty and urethroplasty were carried out using an abdominal skin flap and a bladder/buccal mucosa free graft. RESULTS: Immediate postoperative outcome was excellent in all the patients. One patient had excellent functional and cosmetic results at 5 years, while 2 had a partial dorsal urethral dehiscence resulting in an epispadiac urethra at 2 years, and 1 had necrosis of the distal urethra and was voiding through a scrotal urethrostomy at 9 months postoperatively. Phalloplasty survived and provided an adequate male appearance in all patients. CONCLUSIONS: Opposite gender should not be assigned in patients affected by penile agenesis, who are better raised according to their karyotype and hormonal production. Definitive phalloplasty in adults may achieve good results. Nevertheless, this procedure is generally performed in postpubertal boys and it is not easily available everywhere. Therefore, we believe that social and psychological concerns justified this type of phalloplasty as a palliative preliminary procedure in 3 of our patients. In those countries where definitive forearm phalloplasty is not available our method may also be justified in older children (as in 1 of our patients) as an attempt at a definitive procedure.     

Reconstruction of the female urethra: versatility, complexity and aptness

PURPOSE: Female urethral anomalies, whether congenital or acquired, are rare. Urethral defects are usually if not always associated with variable degrees of incontinence. In this case series we demonstrate the approach in management and surgical outcome of congenital and traumatic urethral anomalies. MATERIALS AND METHODS: The study was conducted on 13 patients with an age range of 2 to 38 years (median 20). Of these patients 4 had female epispadias, 1 had hypospadias, 3 had traumatic urethral loss and 2 had iatrogenic trauma involving the urethra. There were 2 patients with urogenital sinus syndrome and 1 patient had urethral prolapse. RESULTS: After the first stage of repair 4 patients were dry and socially satisfied, and no further intervention was needed. However, in 9 patients a second intervention was necessary to achieve continence. Notably 3 patients empty the bladder through clean intermittent catheterization. CONCLUSIONS: Female urethral defects are usually complex. Congenital causes are associated with severe incontinence. Repair of such defects is challenging, yet 1-stage reconstruction is feasible and potentially successful.     

Lengthening urethral plate with inner preputial skin grafts: a modification of the onlay technique

PURPOSE: The onlay technique for primary hypospadias with severe chordee usually requires dorsal plication for residual curvature. To avoid this we use an inner preputial skin graft to reconstruct the urethral plate. MATERIALS AND METHODS: The urethral plate is divided with a transverse incision near the meatus and penile straightening is achieved. After this a fitting inner preputial skin is grafted between the meatus and urethral plate, and the ventral side of the neourethra is formed with an onlay island flap. RESULTS: A total of 21 patients have undergone this procedure. At a mean followup of 10 months a urethrocutaneous fistula developed in 2 patients and glans dehiscence developed in 1. The complication rate was 14.3%. No anastomotic stricture or megaurethra were found. All patients had excellent cosmetic results. CONCLUSIONS: Lengthening the urethral plate with an inner preputial skin graft allows adequate correction of severe chordee. We think that it is a useful procedure in select cases of primary hypospadias with severe inward curvature.     

Radical bulbar dissection to correct severe chordee and proximal hypospadias

PURPOSE: We describe a technique of proximal hypospadias correction that involves freeing the proximal normal bulbar urethra from perineal attachments to lengthen the ventral penis and decrease chordee. MATERIALS AND METHODS: Correction was performed in 9 patients with a mean age of 11.5 months who had proximal hypospadias and severe chordee that was perineal in 2, mid scrotal in 6 and penoscrotal in 1. After the penis was degloved the bulbar urethra was detethered to or beyond the perineal body without lifting the urethra from the corpora cavernosa. Any remaining penile chordee was corrected and the urethral plate was transected only when chordee persisted. When the urethral plate was intact and the penis straight, tubularized incised plate urethroplasty was done to correct hypospadias in 1 stage. Otherwise 2-stage repair was performed. RESULTS: Using this maneuver penile straightening was achieved in 2 of the 9 patients, resulting in a glanular urethral or penoscrotal meatus. Dorsal plication sutures required in 4 cases resulted in a mid shaft and penoscrotal meatus in 1 and 3, respectively. Residual chordee in the remaining 3 patients necessitated division of the urethral plate and 2-stage repair despite aggressive mobilization of the proximal urethra. Simultaneous tubularized incised plate urethroplasty was then performed in the 4 penoscrotal and 1 mid shaft meatus. All 6 patients who underwent a successful 1-stage procedure have excellent cosmetic results, while 1 required meatotomy. No fistula or chordee was present at a mean of 13.8 months of followup (range 3.9 to 27.1). CONCLUSIONS: This safe, rapid technique may compensate for significant penile tethering and chordee in a subpopulation of patients with proximal hypospadias, such as 6 of the 9 in our study. It also allows successful tubularized incised plate urethroplasty to be done simultaneously.     

Foreskin preservation in penile surgery

PURPOSE: Most hypospadias repairs performed in the United States involve the removal of any foreskin that is not used in the repair, resulting in a circumcised penis. Occasionally, the wishes of the parents or the child are for the final appearance to be that of a normal uncircumcised penis. We report our collective experience from 4 institutions in the reconstruction of the foreskin during penile surgery. MATERIALS AND METHODS: A total of 58 patients underwent penile surgery with reconstruction of the foreskin during a 6-year period. Of the patients 49 underwent hypospadias repair, 8 underwent phalloplasty for chordee correction without hypospadias and 1 underwent reconstruction of the foreskin for a dorsal hood without hypospadias or chordee. Of the 49 hypospadias repairs 46 were distal, 2 mid shaft and 1 proximal shaft. The technique for foreskin reconstruction consisted of a multilayered reapproximation of the lateral margins of the dorsal hood after completion of the urethroplasty and glanuloplasty. RESULTS: Among 49 hypospadias repairs 2 patients had dehiscence of the reconstructed foreskin, with development of a urethral fistula in 1. Of the 58 total patients undergoing penile surgery 56 had retractable foreskin, of whom 4 required postoperative steroid application. Three patients/parents requested a secondary circumcision, 2 for an unacceptable cosmetic result and 1 based on personal preference. CONCLUSIONS: Foreskin reconstruction in association with penile surgery can be performed safely and with a low complication rate in appropriately selected patients. Cases with a higher risk of complications include those involving more proximal hypospadias and those requiring complete degloving of the penile shaft. Of the reconstructions resulting in phimosis most can be salvaged with the application of steroids.     

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.