带蒂皮瓣在复杂性长段尿道闭锁中的应用

目的 探讨带蒂皮瓣在复杂性长段尿道闭锁中的应用. 方法 复杂性长段尿道闭锁患者18例,其中阴茎悬垂部尿道闭锁4例、前尿道完全闭锁7例、前后尿道均闭锁7例.尿道闭锁长度平均15.1(8.7～23.0)cm.伴尿道会阴瘘8例,后尿道直肠瘘7例,假道形成8例.病因:骨盆骨折伴后尿道狭窄术后7例,尿道膀胱内灌注化疗所致4例,球部尿道狭窄术后3例,淋病性尿道狭窄行尿道扩张术后2例,长期留置导尿管所致2例.经会阴切除闭锁尿道,修补直肠瘘;根据尿道缺损长度,应用带蒂皮瓣行一期尿道成形术. 结果 平均随访14(12～18)个月.术后3个月,15例排尿通畅,最大尿流率平均16.9(16.5～21.7)ml/s.1例皮管过长迂曲,排尿困难,切除多余皮管后排尿正常;1例尿道吻合口感染导致再狭窄,切除狭窄段,行尿道端端吻合术后排尿通畅;I例因血肿感染后尿瘘,行尿瘘修补术治愈.术后6个月,17例最大尿流率平均17.0(15.0～22.0)ml/s,1例真性尿失禁无法测定.术后9～18个月,17例最大尿流率平均17.5(15.8～22.5)ml/s. 结论 带蒂皮瓣一期尿道成形术可作为修复复杂性长段尿道闭锁的方法之一.     

复杂性前尿道狭窄的治疗(附78例报告)

目的　探讨复杂性前尿道狭窄手术方法的选择及成功的关键。　方法　对 78例复杂性前尿道狭窄患者采用不同手术方法的尿道成形术 ,其中不同黏膜重建尿道 4 0例 ,带蒂皮瓣一期尿道成形 2 6例 ,狭窄段尿道劈开、二期尿道成形 (Johanson术 ) 12例。　结果　术后随访 6～ 36个月 ,平均 16 .5个月。 6 7例排尿通畅 ,11例效果欠佳。其中黏膜重建尿道组发生尿道皮肤瘘 1例 ,尿道外口狭窄 2例 ,阴茎弯曲 1例 ;带蒂皮瓣尿道成形组发生尿道狭窄 3例 ,尿道皮肤瘘 1例 ,尿道皮肤瘘合并成形段尿道内毛发生成和结石形成 1例 ;Johanson术组发生阴茎弯曲 2例 ,其中 1例合并成形段尿道内毛发生成。　结论　复杂性前尿道狭窄手术方法的选择应根据尿道狭窄段长短、位置和严重程度。尿道狭窄段 <8～ 10cm者宜选用阴茎皮肤 (包括包皮 )带蒂皮瓣 ,阴茎皮肤取材有困难时可选用膀胱或口腔黏膜 ;尿道狭窄段 >10cm者可选用结肠黏膜 ,尤其在膀胱黏膜取材有困难时。     

小阴唇在女性尿道成形术中的应用

我院 1 998年 6月～ 2 0 0 1年 5月在 4例女性尿道缺损患者行尿道成形术中 ,采用小阴唇带蒂皮瓣修复尿道 ,取得满意效果 ,现报告如下。1　资料与方法1 .1 　 临床资料本组 4例 ,年龄 1 6～ 46岁 ,平均 30 .5岁。其中外伤性尿道损伤 2例 ,均伴有骨盆骨折、会阴部皮肤撕裂伤、阴道前壁缺损及不全性尿失禁 ,残存尿道分别长 1 .0、1 .5cm ;因尿道口乳头状瘤疑为癌变在外院行尿道部分切除膀胱造瘘 1例 ,残存尿道口狭窄 ,残存尿道约 1 .0cm ;医源性损伤 1例 ,患者因先天性处女膜闭锁在基层医院行处女膜切开时损伤阴道前壁及尿道远侧端 ,残存尿道…     

显微外科技术纵形带蒂岛状包皮瓣一期修复尿道下裂

目的 探讨显微外科技术纵形带蒂岛状包皮瓣修复尿道下裂的临床效果.方法 伴明显阴茎下弯的尿道下裂患者42例.年龄1～19岁,中位6.4岁.阴茎头冠状沟型6例、阴茎体型28例、阴茎阴囊型8例.4倍显微镜下采用纵形带蒂岛状包皮瓣术式33例,纵形带蒂岛状包皮瓣联合阴囊纵隔皮瓣成形9例.42例重建尿道平均3.6(2.5～6.0)cm. 结果 一次手术治愈38例(90.5%).术后出现尿瘘1例,行尿瘘修补治愈;尿道口狭窄2例,尿道吻合口狭窄1例,行尿道扩张后治愈.41例获随访9～52个月,平均27个月,患者均符合尿道下裂治愈标准. 结论 显微外科技术纵形带蒂岛状包皮瓣行一期尿道下裂修复手术成功率高,并发症少,值得临床推广.     

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。     

显微外科技术在复杂性尿道狭窄手术中的应用

目的 探讨应用显微外科技术治疗复杂性尿道狭窄的手术效果. 方法 本院1997年6月-2011年3月采用显微外科技术施行阴囊后动脉为蒂的阴囊皮瓣尿道成形术治疗复杂性尿道狭窄86例.术中裁剪所需的带血管蒂的阴囊皮瓣,用16 - 18 F硅胶尿管作支架,围绕尿管形成带蒂的皮管,在手术显微镜下以5-0无创伤缝针间断缝合,并于尿道吻合,术后1个月拔出尿管. 结果 临床治疗86例,83例一次手术成功,术后排尿通畅,术后6个月,尿流率测定17.0～26.5 ml/s,成功率96.5％.其中2例术后1年并发尿道内毛发结石,结石发生率2.3％.术后发生尿瘘3例,发生率3.5％. 结论 应用显微外科技术施行阴囊后动脉为蒂的阴囊皮瓣尿道成形术对复杂性尿道狭窄进行修复,手术成功率高,尿道狭窄、尿瘘等术后并发症低,可获得良好的临床效果.     

一期双阴唇带蒂皮瓣尿道成形术治疗女性尿道闭锁（附二例报告）

目的：提高女性外伤性尿道闭锁的疗效,方法：利用双阴唇带蒂皮瓣修复女性外伤性尿道闭锁,结果：2例术后最大尿充率分别为18．2ml/s,17.7ml/s,平均尿流率分别为9．0ml,\/s,10.9/ml/s。2例分别随访15,36个月,均排尿能畅,无需尿道扩张。结论：双阴唇带蒂皮瓣尿道成形术是治疗女性尿道闭锁的一种较为合理有效的方法。     

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.     

带蒂皮瓣尿道成形术治疗前尿道狭窄(附32例报告)

目的:探讨带蒂皮瓣尿道成形术治疗尿道狭窄的技巧。方法:对32例前尿道狭窄患者用带蒂皮瓣尿道成形术一期切开狭窄段同期成形尿道。结果:术后随访,0.5～3年,平均2.2年,25例一次成功,排尿通畅,4例出现狭窄,内切开治愈,3例出现尿瘘,第二次修补治愈。结论:带蒂皮瓣技术对前尿道狭窄,一次完成尿道狭窄切开和尿道成形,成功率高,是一种理想的治疗方法。     

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。     

Transpubic access using pedicle tubularized labial urethroplasty for the treatment of female urethral strictures associated with urethrovaginal fistulas secondary to pelvic fracture

Background

Female urethral injury is rare, and there is no accepted standard approach for the repair of urethral strictures.

Objective

To evaluate the efficacy of transpubic access using pedicle tubularized labial urethroplasty for urethral reconstruction in female patients with urethral obliterative strictures and urethrovaginal fistulas.

Design, setting, and participants

Between January 1996 and December 2006, eight cases of female urethral strictures associated with urethrovaginal fistulas were treated using pedicle labial skin flaps.

Interventions

A flap of approximately 3 × 3.5 × 3 cm of the labia minora or majora with its vascular pedicle was tubularized over an 18–22 Fr fenestrated silicone stent to create a neourethra. This technique was used in five women. Two flaps, approximately 1.5–3.5 cm, were taken from bilateral labia minora or majora and were pieced together to create a neourethra. This technique was used in three patients.

Measurements

We performed voiding cystourethrography and uroflowmetry to assess postoperative results.

Results and limitations

The patients were followed up for 10–118 mo (mean 48.25 mo) after the procedure. There were no postoperative complications. Two patients complained of dysuria, which resolved spontaneously after 2 wk. One patient experienced stress incontinence that resolved after 4 wk. At 3-mo follow-up, one patient complained of difficulty voiding; the urinary peak flow was 13 ml/s, and the patient was treated successfully with urethral dilation. All other patients had normal micturition following catheter removal.

Conclusions

Pedicle labial urethroplasty is a reliable technique for the repair of extensive urethral damage, and a transpubic surgical approach provides wide and excellent exposure for the management of complex obliterative urethral strictures and urethrovaginal fistulas secondary to pelvic fracture.     

Urethroplasty in female-to-male transsexuals

OBJECTIVE: Female-to-male transformation includes total phallic reconstruction. Construction of a neourethra is necessary to achieve the goal of voiding while standing; however urethral fistula and stricture formation occur in a significant percentage of patients. METHODS: 25 patients with primary female transsexualism underwent phalloplasty with a free radial forearm flap, vaginectomy and urethroplasty in a one-stage procedure. In 16 of these patients the fixed part of the neourethra ("bulbar urethra") was constructed from a vaginal flap. In 9 patients flaps of the labia minora (5 patients) or the "urethral plate" (4 patients) were used. RESULTS: In 14 (58%) patients fistulas and/or strictures in the newly constructed urethra occurred. 11 (69%) of 16 patients in whom the "bulbar urethra" was constructed from a vaginal flap experienced fistulas and/or stricture formation. Fistulas and/or strictures occurred in 3 of 5 patients with labia minora flaps and none of 4 patients with the urethral plate procedure. Repair of fistula and strictures was performed by primary closure of fistulas, staged urethroplasty with local pedicle flaps or distant tissue grafts using buccal mucosa (2-6 procedures). CONCLUSION: One-stage total phalloplasty and urethroplasty is associated with a significant rate of fistulas and strictures. However, these complications can be corrected by the techniques used in modern urethral surgery.     

Post-traumatic female urethral reconstruction

Post-traumatic urethral damage resulting in urethrovaginal fistulas or strictures, though rare, should be suspected in patients who have unexpected urinary incontinence or lower urinary tract symptoms after pelvic surgery, pelvic fracture, a long-term indwelling urethral catheter, or pelvic radiation. Careful physical examination and cystourethroscopy are critical to diagnose and assess the extent of the fistula. A concomitant vesicovaginal or ureterovaginal fistula should also be ruled out. The two main indications for reconstruction are sphincteric incontinence and urethral obstruction. Surgical correction intends to create a continent urethra that permits volitional, painless, and unobstructed passage of urine. An autologous pubovaginal sling, with or without a Martius flap at time of reconstruction, should be considered. The three approaches to urethral reconstruction are anterior bladder flaps, posterior bladder flaps, and vaginal wall flaps. We believe vaginal flaps are usually the best option. Options for vaginal repair of fistula include primary closure, peninsula flaps, bilateral labial pedicle flaps, and labial island flaps. Outcomes are optimized by using exacting surgical principles during repair and careful postoperative management by an experienced reconstructive surgeon.     

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.     

Oral mucosal grafts urethroplasty for the treatment of long segmented anterior urethral strictures

Objective  To evaluate the efficacy and safety of using oral mucosal grafts for urethroplasty in the treatment of complex segmented urethral strictures. Methods  Between January 2002 and January 2008, 25 cases of long or multi-segmented urethral strictures (10–18 cm, mean 11.72) were treated using combined two oral mucosal graft urethroplasty. Of the 25 patients, combined double buccal mucosal graft (BMG) urethroplasty was performed in nine patients, double lingual mucosal graft (LMG) urethroplasty in seven patients and combined lingual and buccal mucosal graft urethroplasty in nine patients. Results  Follow-up was obtained for 6–72 months (mean 26.83) post-operatively. Urethrocutaneous fistulas developed in two patients. Urethral strictures developed in one patient undergoing BMG urethroplasty; the patient underwent five urethral dilations, after which he voided well with a urinary peak flow of 26.4 ml/s. Meatal stenosis developed in one patient undergoing LMG and a second operation was required, after which the patient voided well (urinary peak flow of 28.7 ml/s). The other patients voided well and urinary peak flow rates ranged from 16.8 to 49.2 ml/s (mean 28.65 ml/s). Conclusion  Combined two oral mucosal grafts substitution urethroplasty is an effective technique for the treatment of long, segmented urethral strictures.     

舌黏膜尿道成形治疗前尿道狭窄（附80例报告）

目的：研究舌黏膜尿道成形治疗尿道狭窄的有效性和安全性。方法：2006年8月～2008年12月采用舌黏膜尿道成形治疗80例前尿道狭窄,尿道狭窄段2．5～18cm,其中30例为长段尿道狭窄（9～18cm）采用双侧舌黏膜或舌黏膜与颊黏膜或与带蒂包皮拼接尿道成形治疗。尿道成形采用两种术式：保留原尿道板的扩大尿道腔37例;埋藏黏膜条43例。结果：术后随访4～30（平均16．8）个月,7例发生并发症,其中尿瘘4例,再次发生尿道狭窄3例,其余患者排尿通畅,最大尿流率从15．2～54．6（平均28．7）ml／s。结论：舌黏膜是一种修复前尿道狭窄较好的尿道替代物,双侧舌黏膜尿道成形能成功治疗长段、复杂性尿道狭窄。     

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。     

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.     

唇黏膜补片修复前尿道狭窄的疗效观察

目的 探讨应用唇黏膜补片尿道成形术治疗复杂性前尿道狭窄的有效性。方法：2004年3月～2008年9月应用自体下唇黏膜补片行尿道成形术治疗复杂性前尿道狭窄27例。尿道狭窄长度为2．0～7．0cm,平均长度3．9cm。结果：术后随访5～30个月,平均14．1个月。排尿通畅22例（81．5％）,最大尿流率16．9～40．2ml／s,平均23．6ml／s;再次狭窄5例（18．5％）,其中近端吻合口狭窄2例,远端吻合口狭窄2例,分别予以尿道内切开及扩张后,最大尿流率保持在15ml／s以上;1例行黏膜管状尿道成形术患者出现管腔缩窄,予以再次行口腔颊黏膜替代后排尿通畅。下唇取材部位黏膜均愈合良好,1例患者出现口周麻木并持续6个月。结论：下唇黏膜取材方便,取材后供体部位并发症少,适于用作尿道狭窄成形术的替代物。