舌黏膜补片治疗复杂性尿道狭窄的疗效观察

目的：探讨使用舌黏膜补片尿道成形治疗复杂性尿道狭窄的有效性。方法：2006年12月～2009年1月应用舌黏膜补片法治疗复杂性前尿道狭窄患者36例。结果：术后随访3～25个月，平均13．6个月。2例术后出现尿瘘，经再次手术修补后好转；另2例术后出现尿道狭窄，经尿道扩张后治愈。余者术后排尿通畅，平均最大尿流率达23．8ml／s。结论：舌黏膜具有取材方便、取材部位并发症少等优点，是一种治疗前尿道狭窄较好的替代物。     

舌黏膜前尿道成形术方法改良:从切口选择到长段取材

目的:长段尿道狭窄是泌尿外科的棘手问题,舌黏膜尿道成形术是治疗长段尿道狭窄的常用方法,然而,术中黏膜取材不足,术后狭窄复发,口腔和尿道并发症是亟需解决的问题。方法:我们对本中心诊断为前尿道狭窄的患者进行了一项回顾性观察性研究,根据主诉,尿流率,尿道造影结果以及尿道镜下尿道和膀胱的大体外观,所有患者均确诊为尿道狭窄。之后应用我院在舌黏膜尿道重建手术中的多项创新性操作,包括舌黏膜取材,切口选择,移植物替代方法,尿道外口处理。这些患者接受了LMG一期背侧覆盖尿道成形术,术后进行随访。结果:手术时间为2009年12月至2016年3月,随访终止时间为2020年3月,共获得128例患者术后随访数据,患者年龄14～78岁,平均47岁,随访时间45～132个月,平均(81±38)个月,尿道狭窄长度1.0～17.0 cm,平均(7.7±4.1) cm。获取舌黏膜长度2.0～18.0 cm,平均(7.9±4.1)cm,宽度1.0～2.0 cm,平均(1.6±0.4) cm。72例患者在手术前接受过手术或尿道扩张。总体无复发成功率为69.5%。狭窄复发患者的复发时间0.1～101个月,平均(12.4±23.9)个月。18例(17.5%)患者自述术后出现性功能下降。30例患者(28.9%)自诉存在舌疼痛、麻木,有发音改变。结论:本文介绍了4种舌黏膜尿道重建中的技术要点创新,从皮肤切口的选择,舌黏膜取材位置,舌黏膜缝合位置到尿道外口的处理。根据我院大量病例实践显示,以上创新能够显著提高手术成功率,降低并发症发生率。     

舌黏膜尿道成形治疗尿道狭窄的初步报告

目的:探讨舌黏膜补片法尿道成形治疗尿道狭窄的疗效。方法:采用舌黏膜尿道成形治疗尿道狭窄14例。尿道狭窄段3.5~14cm,平均6.2cm;术前耻骨上膀胱造瘘8例,余6例排尿均较为困难,最大尿流率2.5~5.5ml/s,平均3.8ml/s。结果:术后随访2~8个月,1例因伤口感染致尿道皮肤瘘,余患者均排尿通畅,最大尿流率增至22~51ml/s,平均29.6ml/s。结论:舌黏膜具有取材方便、对患者创伤小、抗感染力强等特点,是一种较好的尿道替代物,尤其适合尿道狭窄段<6cm的患者。     

镶嵌式唇黏膜尿道成形术的手术配合

目的总结镶嵌式唇黏膜尿道成形术的手术配合方法.方法对11例尿道下裂术后尿道狭窄患者行镶嵌式唇黏膜尿道成形术,术前做好心理护理、口腔护理;术中严格无菌管理.结果9例获得满意效果;1例术后感染而发生尿瘘,1例发生尿道口狭窄,经处理好转.随访2～6个月,新尿道全部成活,下唇外观无异常.结论术前精心准备,术中密切配合是手术成功的关键.     

舌黏膜与颊黏膜或包皮拼接重建尿道治疗长段尿道狭窄

目的 探讨舌黏膜与颊黏膜或包皮拼接尿道成形治疗多节段或长段尿道狭窄的安全性和治疗效果.方法 尿道狭窄患者11例,年龄24～56岁,平均32岁.其中前尿道长段狭窄7例,狭窄长度10～15 cm,平均12 cm;尿道2～3处狭窄4例.病程6个月～8年.取舌黏膜条与颊黏膜条拼接尿道成形治疗7例,舌黏膜条与包皮瓣拼接尿道成形治疗4例.结果 11例手术顺利.1例舌黏膜与包皮拼接尿道成形患者术后3个月并发尿道外口狭窄,经手术矫正后排尿通畅,术后8个月最大尿流率27.5 ml/s.余10例排尿通畅、尿线粗,术后随访5～12个月,平均10个月,最大尿流率21～36 ml/s,平均26.8 ml/s.结论 舌黏膜与颊黏膜或包皮拼接尿道成形具有取材方便、患者创伤小的特占点,是治疗长段尿道律窄的较好术式.尤其适用于尿道多处狭窄者.     

镶嵌式唇黏膜尿道成形术的手术配合

目的 总结镶嵌式唇黏膜尿道成形术的手术配合方法。方法 对11例尿道下裂术后尿道狭窄患者行镶嵌式唇黏膜尿道成形术，术前做好心理护理、口腔护理；术中严格无菌管理。结果 9例获得满意效果；1例术后感染而发生尿瘘，1例发生尿道口狭窄，经处理好转。随访2～6个月，新尿道全部成活，下唇外观无异常。结论 术前精心准备，术中密切配合是手术成功的关键。     

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.     

舌黏膜镶嵌治疗多次尿道下裂失败患儿中的临床应用和体会

目的:舌黏膜镶嵌尿道成形术为多次尿道下裂手术失败患儿提供了一种尿道修补的新途径,并探索观察其疗效。方法:收集于2009～2014年在我院接受手术的患儿23例,平均年龄4.3岁。23例患儿阴茎局部条件差,多次术后观,尿道狭窄段及瘘口周围较多的瘢痕及挛缩组织,阴茎皮肤破坏严重。患儿均在6个月内接受过口腔黏膜(唇黏膜)代尿道成形术,术后失败,不考虑再次应用口腔黏膜重做尿道。根据入院时患儿手术失败的主要特点分为两组,尿道狭窄组10例,尿道瘘组13例。为再次手术来我院。23例患儿均接受舌黏膜镶嵌尿道成形术一期完成。所取黏膜的长度2～5cm,平均2.8cm;宽度0.5～1.0cm,平均0.7cm。术后随访5个月～2年,平均1.3年。结果:23例患儿发生尿道瘘1例(4.3%),尿道狭窄2例(8.7%),总体并发症率13.1%,手术成功率86.9%。其中尿道瘘组术后发生尿道瘘率1例(7.7%),术后尿道狭窄1例(7.7%),手术成功率84.6%(11/13);尿道狭窄组无一例发生术后尿道瘘,发生尿道狭窄1例(10.0%),手术成功率90.0%(9/10)。结论:多次尿道下裂手术失败的患儿,对于口腔黏膜替代材料不理想者,舌黏膜镶嵌尿道成形术为其提供了一种新的途径。     

异种真皮去细胞基质在尿道重建中的临床应用

目的 观察异种真皮来源的去细胞基质移植物(acellular matrix graft,ACMG)作为尿道狭窄重建手术替代材料应用于临床的安全性与有效性.方法 将ACMG作为尿道重建的替代材料,观察尿路上皮细胞能否长入并形成通畅的新尿道以及有无排斥反应.采用ACMG治疗尿道狭窄病例10例,年龄20 ～ 62,平均36岁.狭窄长度3.0 ～15.0 cm,平均6.9 cm.术时采用狭窄段切除后ACMG尿道套入术或狭窄段切开后ACMG补片尿道修补术,术后6个月拔除尿管,观察该ACMG在人体中有无排斥反应及ACMG辅助尿道重建术的治疗效果. 结果 10例患者拔除尿管后均恢复排尿,尿道造影及尿道镜检查可见术后尿道连续性好,腔内黏膜连续.随访至术后18个月,出现尿道狭窄2例,经尿道内切开扩张后恢复正常排尿,其余患者均可通过尿道正常排尿. 结论 异种真皮ACMG应用于尿道成形术中具有生物相容性良好、能从解剖上和功能上修复尿道的优点,适用于复杂、长段尿道狭窄病例的成形手术.     

阴茎头硬化性苔藓样变及并发前尿道狭窄的临床分析

目的：提高对阴茎头硬化性苔藓样变（LS）及由此引起的前尿道狭窄的认识,并探讨合理的手术治疗方法。方法：15例LS并发前尿道狭窄的患者,年龄27～75岁,尿道狭窄段长4～16cm。采用舌黏膜尿道成形11例、结肠黏膜尿道成形2例;尿道外口切开及前尿道劈开术各1例。所有患者手术同时行LS病变组织病理学检查。结果：术后随访6～12个月（平均10．07个月）。1例游离结肠黏膜尿道成形患者术后2月发生尿道外口狭窄。行尿道外口切开后排尿道通畅;余者术后排尿通畅,Qmax：17．2～32ml／s（平均18．70ml／s）。结论：采用游离黏膜尿道成形治疗LS性尿道狭窄可取得较好效果,但需密切随访病变迁延致尿道再狭窄。     

8 cm以上复杂性尿道狭窄的外科治疗

目的探讨长段尿道狭窄手术方法的选择与疗效。方法对76例尿道狭窄8cm以上的患者采用不同尿道成形术式治疗,其中不同黏膜重建尿道42例（结肠黏膜26例,膀胱黏膜6例,口腔黏膜10例）;带蒂皮瓣一期尿道成形20例;尿道狭窄段切开、二期尿道成形（Johanson术）12例;阴茎段尿道与前列腺部尿道吻合、三期尿道成形术2例。结果术后初期（6个月内）排尿通畅67例（88％）,有并发症者10例。术后1年以上70例,其中获得随访51例,排尿通畅44例,有并发症者8例,其中采用带蒂皮瓣者发生尿道狭窄2例（18％,2／11）;Johanson术者发生阴茎弯曲2例（2／5）,其中1例成形段尿道内毛发生成和结石形成;采用口腔黏膜者发生尿道狭窄1例（1／7）,膀胱黏膜者发生尿道狭窄1例（1／3）,结肠黏膜者发生后尿道狭窄2例（9％,2／23）。结论口腔与结肠黏膜尿道成形对长段尿道狭窄是较理想的术式;结肠黏膜较适合在常规手术治疗失败后或复杂性尿道狭窄10cm以上的治疗。     

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。     

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.     

游离黏膜尿道成形治疗硬化性苔藓样病所致尿道狭窄的疗效观察

目的 提高对硬化性苔藓样病( lichen sclerosus,LS)导致尿道狭窄的认识,观察游离黏膜尿道成形治疗LS所致尿道狭窄的疗效. 方法 2007年1月-2010年12月收治LS所致前尿道狭窄患者36例,年龄27～75岁,平均41岁.尿道狭窄段长5.0 ～20.0 cm,平均11.5 cm.根据尿道狭窄段长短和严重程度选择不同的黏膜组织,其中行口腔内黏膜(舌、颊黏膜)尿道成形27例,结肠黏膜尿道成形8例,另1例老年患者行前尿道劈开.在行尿道重建术前对病变累及的阴茎头、尿道口、尿道行病理学检查. 结果 36例患者术后3周拔除导尿管,排尿通畅;活检结果提示上皮基底部特征性病变,过度角化,上皮层变薄,淋巴细胞浸润等.术后随访6 ～ 50个月,平均22个月.出现尿道外口狭窄3例(8.3％),其中口腔内黏膜尿道成形者2例,结肠黏膜重建尿道者1例,行尿道外口切开后排尿通畅.余患者术后排尿通畅,最大尿流率17.2～47.0 ml/s,平均23.4 ml/s. 结论 采用游离黏膜尿道成形治疗LS所致尿道狭窄疗效较好,但需密切随访,因病变迁延可致尿道再狭窄,尤其是尿道口再狭窄.     

镶嵌式唇黏膜瓣尿道成形术治疗前尿道狭窄

目的：探讨唇黏膜在前尿道狭窄中的应用及效果。方法：对8例前尿道狭窄患者采用镶嵌式唇黏膜尿道成形术治疗。手术以Snodgrass尿道成形术为基础,将狭窄段的尿道完全敞开,取游离的自体唇黏膜瓣镶嵌于背侧劈开的“尿道板”后卷管形成的新尿道。结果：全部病例术后均无明显的尿道狭窄,无尿道憩室形成和尿道口黏膜增生外翻。结论：镶嵌式唇黏膜尿道成形术兼有Snodgrass尿道成形术和唇黏膜尿道成形术的优点,是治疗前尿道狭窄的好方法。     

Dorsal graft urethroplasty for female urethral stricture

PURPOSE: Urethral strictures in females are uncommon, and treatment options and outcome are not well-defined with scanty reports. We describe a new method of urethroplasty for the repair of female urethral stricture. MATERIALS AND METHODS: Three 60-year-old females, each with a history of recurrent urinary tract infections and obstructive voiding symptoms due to urethral stricture, underwent urethroplasty with a dorsal vaginal or buccal mucosal graft. The dorsal aspect of the distal urethra was dissected from the surrounding tissue through a suprameatal incision and the urethral wall was incised through the stricture at the 12 o'clock position. A 1.5 cm wide free graft was harvested from the vaginal wall or buccal mucosa in 1 case, and the mucosal surface was placed upon the urethral lumen and sutured with a running 5-zero polyglactin suture to the open urethra. Indwelling 18Fr urethral and 16Fr suprapubic catheters were left in place for 2 and 3 weeks, respectively. RESULTS: No additional treatment was required during the 1, 8 and 27 months of followup. All patients had normal micturition following catheter removal. CONCLUSIONS: Dorsal graft urethroplasty is feasible and effective for the correction of persistent female urethral stricture.     

Dorsal buccal mucosal graft urethroplasty by a ventral sagittal urethrotomy and minimal-access perineal approach for anterior urethral stricture

OBJECTIVE: To present the technique of dorsal buccal mucosal graft urethroplasty through a ventral sagittal urethrotomy and minimal access perineal approach for anterior urethral stricture. PATIENTS AND METHODS: From July 2001 to December 2002, 12 patients with a long anterior urethral stricture had the anterior urethra reconstructed, using a one-stage urethroplasty with a dorsal onlay buccal mucosal graft through a ventral sagittal urethrotomy. The urethra was approached via a small perineal incision irrespective of the site and length of the stricture. The penis was everted through the perineal wound. No urethral dissection was used on laterally or dorsally, so as not to jeopardize the blood supply. RESULTS: The mean (range) length of the stricture was 5 (3-16) cm and the follow-up 12 (10-16) months. The results were good in 11 of the 12 patients. One patient developed a stricture at the proximal anastomotic site and required optical internal urethrotomy. CONCLUSION: Dorsal buccal mucosal graft urethroplasty via a minimal access perineal approach is a simple technique with a good surgical outcome; it does not require urethral dissection and mobilization and hence preserves the blood supply.     

Substitution urethroplasty of complex and long-segment urethral strictures: a rationale for procedure selection

OBJECTIVES: We evaluated the applications and outcomes of substitution urethroplasty, using a variety of techniques, in 65 patients with complex, long-segment urethral strictures. METHODS: From January 1995 to December 2005, 65 patients with complex urethral strictures >8cm in length underwent substitution urethroplasty. Of the 65 patients, 43 underwent one-stage urethral reconstruction using mucosal grafts (28 colonic mucosal graft, 12 buccal mucosal graft, and 3 bladder mucosal graft), 17 patients underwent one-stage urethroplasty using pedicle flaps, and 5 patients underwent staged Johanson's urethroplasty. RESULTS: The mean follow-up time was 4.8 yr (range; 0.8-10 yr), with an overall success rate of 76.92% (50 of 65 cases). Complications developed in 15 patients (23.08%) and included recurrent stricture in 7 (10.77%), urethrocutaneous fistula in 3 (4.62%), coloabdominal fistula in 1 (1.54%), penile chordee in 2 (3.08%), and urethral pseudodiverticulum in 2 (3.08%). Recurrent strictures and urethral pseudodiverticulum were treated successfully with a subsequent procedure, including repeat urethroplasty in six cases and urethrotomy or dilation in three. Coloabdominal fistula was corrected only by dressing change; five patients await further reconstruction. CONCLUSIONS: Penile skin, colonic mucosal, and buccal mucosal grafts are excellent materials for substitution urethroplasty. Colonic mucosal graft urethroplasty is a feasible procedure for complicated urethral strictures involving the entire or multiple portions of the urethra and the technique may also be considered for urethral reconstruction in patients in whom other conventional procedures failed.     

New 2-stage buccal mucosal graft urethroplasty.

PURPOSE: Previously buccal mucosal grafts used for repairing adult bulbourethral stricture with the 1-stage dorsal technique has provided a satisfactory outcome in our experience. We present the wider use of buccal mucosal grafts for 2-stage urethroplasty. MATERIALS AND METHODS: A total of 24 men 25 to 60 years old (median age 45) with a complex bulbar stricture underwent 2-stage urethroplasty using a buccal mucosal graft to repair the perineostomy. The primary etiology of stricture was traumatic in 4 cases, inflammatory in 16 and unknown in 4. The 2 x 6 cm. graft was harvested from the inner cheek and sutured to the left margin of the urethral mucosal plate with running 6-zero polyglactin suture. Patients were discharged from the hospital within 3 days with a 14Fr silicone urethral catheter in place. Radiological studies and urethroscopy were done 1 year after closure. RESULTS: A final successful outcome with no recurrent stricture was achieved in 23 of 24 men (92.8%) at a median followup of 18 months (range 13 to 32). In 1 case a urethrocutaneous fistula at the initial radiological assessment closed spontaneously after 14 days of catheterization. No urethral diverticula developed. The mean postoperative peak flow rate is 22 ml. per second (range 18 to 25). CONCLUSIONS: Our new 2-stage buccal mucosal graft urethroplasty may be an excellent technique for complex bulbar urethral stricture disease. Our suggestions may increase usefulness of the 2-stage technique for repairing complex strictures due to the avoidance of classic complications.     

Lingual mucosal graft urethroplasty for anterior urethral reconstruction

OBJECTIVE: Evaluate the use of lingual mucosal graft (LMG) in anterior urethral strictures. METHODS: From January 2001 to December 2006, 29 men (mean age, 48.5 yr) with anterior urethral strictures underwent graft urethroplasty with LMG. The mean length of stricture was 3.6cm. Patients with bulbar, penile, or bulbopenile strictures received one-stage dorsal free graft urethroplasties. In patients with failed hypospadias repair we performed a two-stage urethroplasty. Criteria for successful reconstruction were spontaneous voiding with no postvoid residual urine and no postoperative instrumentation of any kind. Clinical assessment included the donor site morbidity. RESULTS: Mean follow-up was 17.7 mo. One-stage bulbar and penile urethroplasties without meatal involvement had an 81.8-100% success rate. Bulbopenile urethroplasties were successful in 60% of the cases, whereas one-stage urethral reconstructions in patients with meatal involvement were successful in 66.6%. The two cases of two-stage urethral reconstruction with LMG and buccal mucosal graft after failed multiple hypospadias repairs were unsuccessful. The overall early recurrence rate was 20.7%. Patients with the graft harvested from the tongue reported only slight oral discomfort at the donor site and difficulty in talking for 1 or 2 d. CONCLUSIONS: The mucosa of the tongue, which is identical to the mucosa of the rest of the oral cavity, is a safe and effective graft material in the armamentarium for urethral reconstruction with potential minor risks of donor site complications. LMG may be used alone for short strictures (<5cm) or in combination with buccal mucosa when longer grafts are needed.