重型尿道下裂一期重建手术

尿道下裂是常见的泌尿生殖系统畸形,手术是治疗本病的唯一方法,至今已知的术式多达300余种.根据矫正阴茎下弯后尿道口退缩位置,可将尿道下裂分为：远端型（阴茎头型、冠状沟型、阴茎远端1/3）,中段型（阴茎中、近端1/3）,近端型（阴茎阴囊型、阴囊型、会阴型）,其中近端型尿道下裂称为重型尿道下裂.重型尿道下裂由于阴茎下弯重,尿道缺损长,一期手术修复难度大.尤其是背侧包皮发育差、包皮不宽裕的患者,单独应用Duckett术往往较难获得成功,且Duckett段尿道过长,受血管蒂游离的长度限制,常不能满足新尿道的充分覆盖,术后易出现尿瘘、阴茎扭转等并发症;而采用游离组织修复虽可节省局部皮肤组织,但并发症较多且有继发创伤.因此对于重型尿道下裂常需多个皮瓣进行联合修复.目前学术界推崇保留尿道板的术式.以下介绍全剥离并保留尿道板加包皮岛状皮瓣尿道成形术一期修复重型尿道下裂的方法.     

尿道下裂个体化手术治疗探讨

目的探讨对尿道下裂患者实施个体化手术治疗的疗效与意义。方法回顾性分析本院收治的98例采取个体化手术治疗的尿道下裂患儿临床资料,其中采取尿道口前移、阴茎头成型术(MAGPI术)14例,尿道板纵切卷管尿道成形术(Snodgrass术)36例,横裁包皮带蒂岛状皮瓣尿道成形术(Duckett术)24例,分期阴茎皮条埋藏法(Duplay术)20例,Duplay+Dukett手术4例。结果 98例患儿总手术成功率82.6%(81/98),MAGPI、Snodgrass、Duckett、Duplay、Duplay+Dukett手术成功率分别为92.8%(12/13)、91.6%(33/36)、79.1%(19/24)、70.0%(14/20)、50.0%(2/4)。术后总并发症发生率:尿道狭窄6.1%(6/98),尿道瘘5.1%(5/98);阴茎外观欠满意6.1%(6/98)。结论在充分理解尿道下裂术式优劣的基础上,根据患儿实际情况,如阴茎下弯程度、尿道外口位置、阴茎、包皮及阴茎头发育情况,选择个体化手术方案是尿道下裂患儿切实有效可行的临床治疗模式。     

改良Duckett+Duplay术治疗小儿Ⅲ度尿道下裂

目的评价改良Duckett+Duplay术式治疗Ⅲ度尿道下裂的临床疗效,探讨提高尿道下裂疗效的手术方式.方法 2007年1月至2009年12月,作者采用改良Duckett+Duplay术式治疗Ⅲ度尿道下裂患儿52例,平均年龄(3.40±2.13)岁,其中阴茎阴囊型35例,会阴型17例.尿道缺损2.5～7cm.同期采取单纯Duckett术式治疗Ⅲ度尿道下裂37例.结果采取单纯Duckett术式患儿中,治愈25例,出现尿瘘7例,尿道狭窄2例,尿道憩室3例;采取改良Duckett+Duplay术式患儿中,治愈47例,出现尿瘘4例,尿道憩室1例.均于半年后再次手术治愈.经X2检验,两种术式治愈率差异有统计学意义(X2=7.283,P<0.01).结论改良Duckett+Duplay术式一期修复小儿Ⅲ度尿道下裂效果良好,可作临床推广.     

尿道下裂手术方法选择再认识

目的 探讨不同类型尿道下裂手术方法的选择。方法 总结2000-2003年治疗490例尿道下裂的临床经验。无阴茎下弯或轻度阴茎下弯通过阴茎背侧白膜折叠矫正后的尿道下裂手术方法，包括：尿道口位于舟状窝患儿选用尿道口前移、阴茎头成型(MAGPI)；尿道口位于阴茎体、阴茎根患儿用加盖岛状包皮瓣法(Onlay)；Snodgrass法用于尿道板发育好的远端前型尿道下裂以及部分再次手术病例；合并阴茎下弯的尿道下裂应用带蒂岛状包皮瓣尿道成型术(Duckett)及Duckett Duplay术式。结果 各种手术方法的成功率：MAGPI为95．5％(21／22例)；Snodgrass 93．3％(14／15例)，Snodgrass用于再次手术的患儿效果72.4％(21／29例)；Onlay 95．5％(213／223例)；Duckett 90．8％(157／173例)；Duckett Duplay 81．6％(31／38例)。结论 应根据尿道下裂有无合并阴茎下弯及尿道开口位置和阴茎发育的状况选择手术方法。     

分期Duckett术式治疗重度尿道下裂的疗效评价

目的：通过与一期 Duckett 术式手术效果进行比较,探讨分期 Duckett 术式治疗重度尿道下裂的应用及价值。方法2009年1月至2014年10月,我们收治重度尿道下裂72例,均为阴茎阴囊交界型或会阴型尿道下裂,患儿第1次手术时年龄2～3岁,平均2.4岁。其中38例采用管形包皮岛状皮瓣法一期尿道成形术,即一期 Duckett 术式,为 A 组,成形尿道长度4～6 cm。34例采用分期手术,一期手术中矫正阴茎下弯后,采用管形包皮岛状皮瓣法成形部分尿道,即分期 Duckett 术式,为 B 组;第一期成形尿道长度为3～4.5 cm;术后1年行二期尿道成形术,成形尿道长度1.5～2.5 cm,两期手术成形尿道总长度4～6 cm。结果两组均获随访,术后随访6个月至5年,平均3.5年,无一例阴茎下弯复发。A 组有7例（7／38,18.5％）术后发生尿瘘。B 组有3例（3／34,8.8％）术后发生尿瘘,均出现在二期尿道成形术后。A 组有4例出现尿道狭窄（4／38,10.5％）,B 组1例出现尿道狭窄（1／34,2.9％）。A组有4例出现尿道憩室（4／38,10.5％）,B 组无一例尿道憩室发生。A 组手术成功率为60.5％,B 组手术成功率为88.3％,差异有统计学意义（P ＝0．008）。结论与一期 Duckett 术式相比,分期 Duckett术式治疗重度尿道下裂,术后并发尿瘘、尿道狭窄和尿道憩室少。分期 Duckett 术式有效降低了重度尿道下裂的手术难度和并发症的发生率,提高了复杂尿道下裂的疗效,具有较好的临床应用价值。     

利用横断后尿道板组织修复近段型尿道下裂的术式研究进展

尿道下裂(hypospadias)是儿童泌尿生殖系统常见的先天畸形之一,发病率较高且有增加趋势,其中近段型尿道下裂占比逐年增加,严重影响患儿阴茎发育.近段型尿道下裂多合并严重阴茎下弯,手术治疗以横断尿道板术式为主,术后并发症发生率明显高于保留尿道板术式.目前,Duckett术式的应用最为广泛,但存在手术操作困难以及尿道...     

尿道下裂术后尿道狭窄与术式选择的关系研究

目的研究尿道下裂术后尿道狭窄与术式选择之间的关系。方法总结1995年6月至2005年6月经本院治疗的324例尿道下裂尿道成形术病例资料,发现术后合并尿道狭窄43例,分析不同术式、狭窄发生部位与狭窄发生率之间的关系。结果尿道口前移龟头成形术(MAGPI),加盖岛状皮瓣法(OnlayIslandFlap)的尿道狭窄发生率为0%,Mathieu法的尿道狭窄发生率为9.4%。而Dennis-Brown法与膀胱粘膜法的尿道狭窄发生率较高,分别为28.3%、40.0%。结论对于阴茎头、冠状沟型尿道下裂应尽量采用MAGPI法;阴茎体型尿道下裂宜采用Mathieu法;而近端型尿道下裂宜采用OnlayIslandFlap或Duplay Duckett法;只有当没有或缺少材料时才考虑采用膀胱粘膜法。     

改良Koyanagi术式一期治疗重型尿道下裂的疗效评价

目的评价改良Koyanagi术式一期治疗重型尿道下裂的疗效。方法回顾性总结重庆医科大学附属儿童医院2009年2月至2018年10月151例采用Koyanagi术式(为Koyanagi组)和188例采用Duckett术式(为Duckett组)治疗的重型尿道下裂患儿临床资料,对两种术式的治愈率、并发症发生情况进行比较分析,评价我院改良Koyanagi术式的疗效。结果Koyanagi组发生尿瘘17例,尿道狭窄15例,尿道憩室2例,尿道感染3例,伤口裂开2例;Duckett组发生尿瘘37例,尿道狭窄27例,尿道憩室6例,尿道感染11例,伤口裂开6例;Koyanagi组治愈率显著高于Duckett组,尿瘘发生率显著低于Duckett组(P<0.05)。两组家长对外观的满意度均显著低于非手术泌尿外科医师(P<0.05)。结论我院的改良Koyanagi术式操作更简便,术后并发症少,术后阴茎外观较好,治疗重型尿道下裂疗效确切,可作为治疗重型尿道下裂的新选择。     

国内医院尿道下裂治疗现状调查

目的 了解国内尿道下裂治疗基本现状,为提高尿道下裂治疗水平提供参考意见.方法 对国内部分治疗尿道下裂医院的主治医师以上级别的医生,通过问卷调查的方法了解尿道下裂治疗情况.调查主要内容包括:尿道下裂患儿手术年龄、术式选择、术前治疗及术后并发症处理方式等.统计不同术式术后并发症发生情况.按年龄及手术量对数据进行分组,每年手术量≤100例的一组(50人),＞100例的一组(32人);手术医生年龄≤50岁一组(59人),＞50岁一组(23人).结果 我们共发出90份问卷,回收90份问卷,有效问卷82份.建议手术年龄6～30个月81份(98.8％).手术方式:对于不合并阴茎下弯的患儿,以尿道口前移阴茎头成型(MAGPI)或尿道板纵切卷管(TIP)为主;对于合并阴茎下弯的患儿,以TIP、Duckett带蒂岛状包皮瓣尿道成形或分期手术为主.手术医生年龄对合并阴茎下弯的阴茎体型尿道下裂手术方法的选择有影响.每年手术量100例以上的医生,对于合并下弯的阴茎阴囊型和阴囊型尿道下裂更多偏向使用Duckett一期修复(75.0％和53.1％).对于阴茎下弯的处理,下弯＜15°,不处理占48.8％(40/82),行阴茎背侧白膜紧缩占41.5％(34/82);下弯15°～35°,行阴茎背侧白膜紧缩占30.5％(25/82),行横断尿道板占59.8％(49/82);下弯＞35°,行横断尿道板占80.5％(66/82).尿道瘘和尿道狭窄是术后主要并发症.结论 目前国内常用的尿道下裂手术方式包括MAGPI、TIP、Duckett及分期手术.医生的年龄(50岁为界)及每年手术量(100例)对无阴茎下弯的尿道下裂手术选择的影响差异无统计学意义.     

Duckett术式治疗尿道下裂74例

目的分析Duckett术式治疗尿道下裂的临床疗效,探讨并发症的预防措施。方法回顾性分析作者应用Duckett术式治疗的74例尿道下裂患儿临床资料。结果74例患儿均一期完成手术,术后随访3个月至2年,发生尿道瘘5例,其中2例已行尿道瘘修补术治愈,1例术后自行愈合,2例术后未满1年,待行补瘘手术。发生尿道狭窄2例,均为尿道外口狭窄,经尿道扩张并持续使用8F气囊导尿管1个月治愈,无再次手术病例。结论Duckett术式是治疗中、重度尿道下裂的常用方法,通过引进精细的手术器械,提高手术技巧,可显著降低术后并发症的发生率。     

Factors affecting outcome of one-stage anterior hypospadias repair: analysis of 422 cases

The repair of hypospadias is among the most difficult problems in urology, as it demands the construction of a well-functioning urethra and a good cosmetic appearance. We performed a retrospective analysis of 422 cases subjected to one-stage anterior hypospadias repair between 1982 and 1999 in our clinic and investigated the effects of factors like degree of hypospadias, surgical technique, and the surgeon's experience on outcome. The operations used were MAGPI (91), urethral advancement (10), Mathieu (260), modified Allen-Spence (50), onlay island flap (5), and double-faced island flap (6) procedures. The early complication rate was 18%, while the final success rate following secondary interventions was 95%. The complications included fistula formation in 49 cases (12%), flap necrosis in 12 (3%), meatal problems in 12 (3%), residual chordee in 4 (1%), and urethral stricture in 1 (<1%). Complication rates were significantly higher if the meatus was proximal or there was severe chordee and in the first 6 years of the study. The flap procedures were associated with a higher complication rate. It is concluded that one-stage procedures are successful in the repair of anterior hypospadias in experienced hands with proper patient selection. Accepted: 21 March 2001     

尿道下裂术式选择与术后尿道狭窄发生的相互关系

分析尿道下裂尿道成形不同术式与术后尿道狭窄发生之间的关系。方法总结１９８７年６月至１９９７年６月本院治疗的４３４例尿道下裂尿道成形术资料，术后合并尿道狭窄５０例，分析不同术式，狭窄发生部位及狭窄发生率之间的关系。结果尿道口前移，龟头成形术（ＭＡＧＰＩ）、Ｏｎｌａｙｉｓｌａｎｄｆａｌｐ法（加盖岛状皮瓣诉狭窄率为０，Ｍａｔｈｉｅｕ法的狭窄率较低，为９．３％，而Ｄｅｎｎｉ－Ｂｒｏｗｎ与膀胱粘膜法的狭窄率     

前型尿道下裂患儿尿道口前移龟头成形术后尿道功能的评估

目的探讨尿道口前移龟头成形术（MAGPI）对前型尿道下裂患儿尿道功能的影响。方法2008年8月到2011年8月作者收治16例男性前型尿道下裂患儿,年龄2—10岁,平均4岁9个月,其中龟头型2例（12．5％）,冠状沟型14例（87．5％）;8例（50．0％）伴轻度阴茎下弯。依据Duckett报道的手术方法对16例患儿行MAGPI手术治疗。术前术后行尿流率检查。结果患儿均一次手术获成功。术后2～3个月尿流率检查提示最大尿流率、平均尿流率术前术后比较,均有统计学意义,最大尿流率由术前的（9．5±2．7）mL／s增加到术后（11．6±2．0）mL／s（P=0．022）;平均尿流率（6．2±1．6）mL／s增加到术后（7．7±1．4）mL／s（P=0．009）。结论MAGPI手术方法简单,成功率高,术后无尿道狭窄发生,患儿尿道功能较术前改善,对于合适的前型尿道下裂患儿是一种很好的手术方法。     

Hypospadias outcome in the first 3 years after completing a pediatric urology fellowship

IntroductionThe requirements of hypospadias surgery today not only include the creation of a straight phallus with optimal meatal placement but also call for excellent cosmetic outcomes with minimal complications. Specialty fellowship training as well as advanced surgical materials and techniques allow for consistent, successful results. We report the outcomes of hypospadias surgeries performed by two academic Pediatric Urologists in the first 3 years of practice after completing a 2-year fellowship.Patients and methodsA retrospective chart review of all patients with hypospadias treated by two surgeons (DF and JC) between July 2004 and August 2007 was performed. The two surgeons had completed a 2-year Pediatric Urology fellowship at two different institutions (Johns Hopkins and Texas Children's Hospital). Level of hypospadias, patient age, type of repair and follow up as well as complications were recorded. Midshaft and distal hypospadias were classified as distal.ResultsIn all, 187 patients were operated on. No significant difference in numbers and complications occurred between the two surgeons. Distal hypospadias was found in 149, proximal in 29, and penoscrotal or perineal was found requiring a two-stage repair in nine patients. Distal hypospadias was repaired using either dorsal plate incision with tubularization (TIP) (n = 112) or meatal advancement and glanuloplasty (MAGPI) (n = 37). All proximal lesions were repaired using TIP. All patients were seen after 1–2 weeks, and 6 and 12 months postoperatively. Fistulae occurred in 10 patients (three in distal, four in proximal, and three in two-stage repairs) for an overall fistula rate of 5.3%. Meatal obstruction occurred in three distal repairs and one two-stage repair, diverticulum in one proximal. No complications occurred with MAGPI repairs. All complications, except for one, were successfully repaired in a single operation.ConclusionModern hypospadias surgical techniques pioneered through decades of surgical innovation can now be successfully transferred to the new generation of specialty-trained Pediatric Urologists. Modern pediatric fellowship training allows performing distal hypospadias repair with a minimal fistula rate of 2.8%. Proximal hypospadias remain more challenging with complication rates of 13.8% for one-stage and 33.3% for two-stage repairs.     

Outcomes in distal hypospadias: a systematic review of the Mathieu and tubularized incised plate repairs

AimTo compare complication rates after distal hypospadias surgery using the tubularized incised plate (TIP) and Mathieu techniques.MethodsFor this meta-analysis, the Medline (1990–2009), Embase (1990–2009) and Cochrane databases were searched using the keyword ‘hypospadias’. Inclusion criteria were: i) primary repairs; ii) distal hypospadias; iii) paediatric case series; iv) standard Mathieu and TIP techniques; v) complication data obtainable from the paper. Cases were only included in the denominator for each complication if explicitly identified in the paper. Fisher’s exact was used for statistical analysis, with P < 0.05 considered significant.Main results129 papers were selected for full analysis; 23 papers met the inclusion criteria comprising 1872 TIP repairs and 1496 Mathieu repairs. We identified an increased incidence of urethral fistulae with the Mathieu technique (3.8% vs 5.3%, P = 0.028); however, this is lost on subgroup analysis. An increased incidence of meatal stenosis was identified in the TIP group (3.1% vs 0.7%, P < 0.001).ConclusionsThere is no clear consensus on the ideal method of repair for distal hypospadias. Both the Mathieu and TIP techniques have been shown to have low rates of postoperative complications. Comparison between series is difficult because of a lack of consistency in reporting complications and follow up. We advocate uniform standards for reporting outcomes of hypospadias.     

保留尿道板手术在尿道下裂治疗中的应用

目的：探讨保留尿道板手术在尿道下裂的疗效，方法。总结分析189例保留尿道板的尿道下裂修复手术。结果：保留尿道板手术总成功例数177／189（93．65％），其中采用尿道口基底皮瓣法（Mathieu法）39／42例（92．86％），加盖岛状皮瓣法(Onlay island flap法）138／147例（93．88％），结论：保留尿道板手术适用于无或伴有轻度阴茎下弯的尿道下裂治疗，可按尿道口位置选择手术方法：冠状沟型及阴茎体前型尿道下裂采用Mathieu法，阴茎体型及阴茎根型尿道下裂采用Onlay island flap法。     

Preputioplasty associated with urethroplasty for correction of distal hypospadias: A prospective study and proposition of a new objective scoring system for evaluation of esthetic and functional outcome

ObjectiveMost surgical procedures for correction of hypospadias involve the removal of foreskin resulting in a circumcised penis. We report our experience and the medium-term results in the reconstruction of the foreskin during the correction of distal hypospadias.Materials and methodsBetween January 2007 and December 2011, 445 patients aged between 8 and 120 months underwent surgical correction of hypospadias. In 354 out of 445 patients, we performed the reconstruction of the foreskin. Urethroplasty was performed according to either the TIPU (tubularized incised urethral plate urethroplasty; Snodgrass) technique (233/354, 66%) or MAGPI (meatal advancement glanduloplasty incorporated) procedure (121/354, 34%). In 91 out of 445 patients urethroplasty was performed using classic TIPU technique and they were circumcised. The cosmetic and functional results were evaluated using the Hypospadias Objective Penile Evaluation (HOPE) scoring system.ResultsAt a 12 months follow-up, 300 patients (84.7%) had retractable foreskin while 54 patients (15.3%) required postoperative steroid application. We had a total complication rate of 8.7%. As for preputioplasty, 16 patients (4.5%) had partial or total dehiscence of the reconstructed foreskin, one patient was circumcised for persistent phimosis (0.2%). As for urethroplasty complications, we recorded 11 fistulas (3.1%) and three stenosis (0.9%). The complication rate of the control group of circumcised patients was of 3.3% (2 fistulas [2.1%] and 1 stenosis [1.2%]).ConclusionsOur experience shows that foreskin reconstruction can be performed successfully in selected patients with distal hypospadias. However, preputioplasty add an additional 4.7% complication rate. As for the complications of urethroplasty, it seems that preputioplasty does not increase the incidence of complications on the urethra reconstruction. We propose a new objective scoring system (modified HOPE score) for evaluation of esthetic and functional outcome.