膀胱软镜联合尿道内切开镜会师治疗骨盆骨折术后尿道狭窄(附12例报告)

目的:评估膀胱软镜联合尿道内切开镜会师治疗骨盆骨折术后尿道狭窄的临床疗效。方法:采用膀胱软镜联合尿道内切开镜会师治疗骨盆骨折术后尿道狭窄男性患者12例,中位年龄33(19～54)岁。术前行尿道探子会师+尿道造影对狭窄部位和长度进行评估,经造瘘口置入膀胱软镜探及尿道内口,经尿道外口置入尿道内切开镜并调暗光源,在膀胱软镜光源引导下行尿道狭窄内切开术,并对手术时间、失血量、并发症进行记录。术后留置尿管1个月,拔除尿管后每月进行随访,术后3个月行尿道造影、尿流率及国际勃起功能指数问卷(IIEF)评分评估。结果:手术均获成功,手术时间(37±12)min,手术后血红蛋白较术前降低(4.5±2.3)g/L,拔除尿管后无尿失禁,术前术后IIEF评分无明显变化(12.4±6.6vs 13.1±7.0,P>0.05)。随访6～22个月,9例无需进一步处理,排尿正常;3例拔除尿管后出现排尿困难和继发性尿道狭窄,给予每周1次尿道扩张,2例连续4周、1例连续6周尿扩后可置入F18尿道探子,排尿正常,术后3个月Qmax均在(16.2±5.8)ml/s以上。结论:膀胱软镜联合尿道内切开镜会师治疗骨盆骨折术后尿道狭窄简便易行,创伤小,并发症少,近期及远期疗效满意,可作为骨盆骨折术后尿道狭窄的首选治疗方法。     

不同的尿流改道在尿道下裂手术中的应用

目的观察不同的尿流改道方法在尿道下裂手术中的应用效果。方法回顾性分析2010年1月至2014年1月的74例尿道下裂患者,采用单纯留置Foley导尿管和U型尿道支架管联合耻骨上膀胱造瘘引流尿液,一期尿道成形。结果 74例患者术后获随访10~46个月,出现膀胱痉挛12例,切口感染4例,尿瘘8例。与单纯留置导尿管的术后膀胱痉挛、切口感染、尿瘘发生率相比较,U型尿道支架管联合耻骨上膀胱造瘘法的并发症发生率明显降低(P0.05)。结论尿道支架管联合耻骨上膀胱造瘘是一种有效、可行的尿流改道方法。     

腔内尿道会师法治疗复杂性男性尿道狭窄

目的总结腔内尿道会师法治疗复杂性尿道狭窄的经验。方法16例男性复杂性尿道狭窄患者,术前行耻骨上膀胱造瘘术,硬膜外麻醉下经尿道外口置入尿道内切开镜,经耻骨上膀胱造瘘口置入一软性膀胱镜经膀胱颈口顺行进入尿道。经内切开镜或软性膀胱镜插入一细输尿管导管,经正道通过狭窄段尿道。沿此导管用内切开刀切开狭窄段尿道,沿正道进入膀胱,再用Otis刀彻底切开狭窄段。结果16例患者均成功地顺利完成了腔内尿道会师手术,拔除尿管后排尿通畅。平均手术时间122min。平均最大尿流率18mL/s。随访15月,F20尿道扩张器可以顺利通过。结论利用内切开镜和软性膀胱镜腔内尿道会师治疗复杂性尿道狭窄,方法简单易行,疗效确切可靠,成功率高。     

球部尿道海绵体损伤后迟发性出血伴休克

球部尿道损伤多因尿道内、外暴力所致 ,绝大多数病人经留置导尿管 ,耻骨上膀胱造瘘均可治愈。损伤后发生迟发性出血伴休克者极为少见 ,现将作者收治的 3例报告如下。1　临床资料1 1　例 1　男性 ,17岁。会阴部骑跨伤耻骨上造瘘术后 10ｄ入院 ,次日晚突发尿道大量出血 ,ＢＰ :8/4ｋＰａ。急诊手术见膀胱内大量血块 ,未见活动性出血迹象。尿道镜可见尿道连续性完整 ,3 5ｃｍ长球部尿道粘膜挫伤、水肿、有多处出血创面。留置尿管 ,输血80 0ｍｌ。术后适度牵拉气囊导尿管 ,雌激素治疗 ,3周后拔除尿管 ,排尿及勃起功能正常。1 2　例 2　男性 ,2 7…     

良性前列腺增生患者经耻骨上膀胱造瘘与经尿道置管两种方法行排尿期压力-流率测定的比较与评价

目的:通过对良性前列腺增生(BPH)患者经耻骨上膀胱造瘘与经尿道置管两种方法行排尿期压力-流率测定的结果比较,探讨应用前者的必要性。方法:对23例平均年龄为69.3(57~77)岁的患者同时以经耻骨上膀胱造瘘与经尿道置管两种方法行排尿期压力-流率测定,对相应参数以配对t检验进行统计比较。结果:①经耻骨上膀胱造瘘与经尿道置管相比,最大尿流率(Qmax)提高约1.19 ml/s(P<0.05);最大尿流率时逼尿肌压力(Pdet,Qmax)减少约10.57 cmH2O(P<0.05);组特异性尿道阻力因子(URA)减少约11.39 cmH2O(P<0.01);AG(Pdet,Qmax-2Qmax)数减小约12.94(P<0.01);最大膀胱容量增加约66.61 ml(P<0.01)。②分别以schafer图所示、AG数>40为判定梗阻的标准,经耻骨上膀胱造瘘的梗阻数均为16(69.6%),而以尿道置测压管均为20(87.0%),前者例数比后者减少。结论:行排尿期压力-流率测定时,经耻骨上膀胱造瘘与经尿道置管两种方法各有利弊,对BPH患者,主张选择前者。对于其它疾病患者应视具体情况而定。     

输尿管镜下钬激光治疗尿道皮肤瘘1例

1临床资料患者,男性,24岁,2010年11月因车祸致全身多处骨折、骨盆骨折、后尿道断裂,在当地医院急救,留置尿管,未引出尿液,行膀胱切开造瘘,术中发现尿管穿出尿道至耻骨下,当时即拔出尿管,病情稍稳定后转入我院创伤骨科,后转我科治疗尿道断裂及膀胱造瘘口周围组织感染。尿道造影发现尿道完全闭锁,狭窄段位于膜部,约2cm,     

经尿道前列腺汽化电切术后尿道狭窄并急性尿潴留38例临床分析

目的探讨经尿道前列腺汽化电切(TUVP)术后尿道狭窄并急性尿潴留的治疗效果。方法对38例TUVP术后后尿道狭窄并发急性尿潴留BPH患者的临床资料进行回顾性分析。结果 38例患者中9例(23.68%)一次性导尿成功,8例患者膀胱镜下实施尿道扩张后,成功留置导尿管,21例患者综合应用输尿管镜、电切镜及冷刀等进行治疗后导尿成功。本组患者均在急诊情况下采用不同方法实现膀胱减压,36例拔出尿管后均自行恢复排尿,2例患者(5.12%)拔出尿管后自行排尿失败后改行耻骨上膀胱穿刺造瘘。结论对于TUVP术后尿道狭窄并急性尿潴留患者,急诊情况下应用各种尿道腔内治疗可有效缓解患者临床症状,减轻痛苦,提高患者术后生活质量。     

输尿管镜在尿道狭窄与闭锁中的临床应用总结

目的:总结输尿管镜在尿道狭窄和尿道闭锁临床应用。方法:应用输尿管镜技术治疗尿道狭窄及闭锁72例,外伤性狭窄27例,炎性狭窄30例,前列腺电切术后狭窄13例,2例为先天性后尿道瓣膜。结果:72例患者69例留置导管成功,3例进输尿管镜失败,改为开放手术。68例拔除尿管后均能有效排尿。4例因再发狭窄行耻骨上膀胱造瘘。结论:输尿管镜在尿道狭窄闭锁的诊断、治疗中应用广泛,输尿管技术与其他技术手段相结合,能显著提高尿道狭窄腔内治疗效果。     

经膀胱造瘘口引出双侧输尿管单J管处理宫颈癌放疗后膀胱阴道瘘的疗效分析

本文回顾性分析我院2015年1月至2021年10月收治的8例宫颈癌放疗后出现膀胱阴道瘘患者的临床资料, 均行局麻下膀胱造瘘, 膀胱镜下留置双侧输尿管单J管, 单J管经膀胱造瘘口引入造瘘袋内。术前患者均长期穿纸尿裤, 生活质量评分(QOL)为(5.3±0.5)分;术后使用尿垫, 0～2块/日, QOL为(2.5±0.5)分, 患者身体异味基本消失。对于各种原因不能手术或手术反复失败的膀胱阴道瘘, 采用经膀胱造瘘口引出双侧输尿管单J管治疗, 可通过较小的创伤, 提高患者的生存质量。     

超声引导G18套管针穿刺在不充分充盈膀胱造瘘中的应用

目的 探讨B超引导下G18套管针穿刺在不充分充盈膀胱造瘘中的有效性及安全性.方法 对2例后尿道断裂患者,4例球部尿道断裂,1例腰椎手术术前引流尿液患者和2例神经外科手术术前引流尿液患者,因膀胱均不充分充盈,B超检查尿量约100mL,耻骨上区扪不到充盈膀胱,采用B超定位下G18套管针穿刺膀胱,穿刺成功后注入生理盐水200 ～ 400mL,充分充盈膀胱,然后再行膀胱穿刺造瘘.结果 9例患者均穿刺造瘘成功,手术时间10～ 15min,未出现肠管损伤、前列腺损伤等并发症.结论 采用B超定位下G18套管针穿刺行不充分充盈膀胱造瘘术,具有操作简单、安全有效等优点.     

Trauma to the anterior urethra: diagnosis and management

Injuries to anterior urethra are uncommon, mainly due to blunt trauma, and rarely associated with pelvic fractures or life threatening multiple lesions. Straddle type injury is the most frequent lesion, in which the immobile bulbar urethra is crushed or compressed on the inferior surface to the pubic symphysis. Diagnosis of urethral injury is easy, suspected due to trauma circumstances, presence of urethrorragy or initial hematuria, and eventually difficult micturition and penile scrotal for perineoscrotal hematoma. It should always be confirmed and classified by retrograde urethro-gram, realized either immediately or after a few days. Initial acute management is suprapubic cystostomy, if possible before any attempt of urethral catheterization or miction. Urethral contusions only require this urinary diversion or urethral catheter for a few days and usually heal without any sequelae. Management of partial and complete disruptions remains controversial: suprapubic diversion only and secondary endoscopic or open surgical repair of the urethral stricture that occurs in the great majority of the cases (always after complete disruption), early endoscopic realignment and prolonged urethral catheterization (4 for 8 weeks according to the lesion), in partial disruptions, more controversial in complete disruptions; delayed (after a few days) open surgical repair (urethrorraphy) that is the preferred European and French attitude for complete disruptions. Penetrating anterior urethral trauma and urethral lesions associated with penile fracture require immediate surgical exploration and repair if possible. After anterior urethral disruption, the main morbidity is urethral stricture very often requiring surgical treatment (visual urethrotomy if the structure is short, end to end spatulated urethrorraphy, flap or graft urethroplasty if longer).     

Urethral injury in the multiple-injured patient

A total of 74 patients with urethral injury due to external trauma consisted of 48 posterior urethral injuries (25 complete rupture, 23 partial rupture) and 26 anterior urethral injuries (two complete rupture, 16 partial rupture, and eight contusion). The diagnosis was made by retrograde urethrography. All 48 patients with posterior urethral injury had associated injuries, including a fractured pelvis in 46, and a mortality rate of 33%. Only seven of the 26 patients with anterior urethral injury had associated injuries and a mortality rate of 14%. The management of posterior urethral injury is changing from primary realignment of the ruptured urethra to suprapubic cystostomy alone and followed later by urethral surgery for the resulting stricture. The impotence rate is significantly lower with management with suprapubic cystostomy alone. However, the type of pelvic fracture, the urethral injury itself disrupting neurovascular structures, and the surgical dissection (initial primary realignment or delayed urethroplasty) must be investigated before it can be determined whether the impotence associated with pelvic trauma is caused by the injury itself or by the surgical dissection undertaken to reconstruct the urethra.     

小儿尿道损伤的诊断与治疗

目的：探讨小儿尿道外伤及外伤后尿道狭窄的诊治经验。方法：在8例新鲜完全性后尿道断裂患儿中,3例行经耻骨上与会阴入路的尿道修复术,2例行尿道会师术,2例行膀胱造瘘术,1例女童行经耻骨后尿道吻合术。在18例陈旧性后尿道外伤患儿中,10例行经尿道内切开（TUR）术,4例行经耻骨、会阴联合入路修复术,4例行经会阴修复术。结果：8例新鲜后尿道断裂患儿中,术后出现尿道狭窄5例,不完全尿失禁1例。18例陈旧性尿道蛱雅患儿中,行TUR的成功率为60．0％,经会阴及经耻骨、会阴联合入路行尿道修复术的成功率为91．7％,有不完全尿失禁5例,会阴尿道造瘘尚未修复1例。结论：后尿道外伤的急症处理非常重要,如患儿情况允许,应尽量行经耻骨、会阴联合入路尿道修复术。经尿道内切开适用于绝大多数单纯性后尿道狭窄,经耻骨、会阴联合入路或经会阴修复尿道适用于复杂性后尿道狭窄或TUR失败者。     

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。     

前尿道损伤早期处理的治疗体会

目的 探讨前尿道损伤早期处理方式的选择.方法 回顾性总结2001年9月至2011年6月我科47例尿道损伤患者的临床资料,分析术后并发症及排尿情况.结果 47例患者随访41例,随访时间1～84个月,术后2～6周拔除尿管;采用膀胱穿刺造瘘术3例,留置导尿8例,输尿管镜尿道置管术18例,腔镜下尿道会师术4例,尿道修补术或断端吻合术14例(术后会阴伤口感染2例,尿漏2例),术后31例排尿良好,尿道狭窄10例,失访6例.结论 前尿道不全断裂首选输尿管镜尿道置管术,不成功时行腔镜下尿道会师术,而对于前尿道断裂仍宜行尿道断端吻合术.     

Posttraumatic complete and partial loss of urethra with pelvic fracture in girls: an appraisal of management

PURPOSE: Urethral injury in girls accompanying fracture of the pelvis is rare. We present our experience with 5 such complex cases and review the literature to define the types of problem and determine appropriate management. MATERIALS AND METHODS: We report on 5 girls with posttraumatic urethral injuries and pelvic fracture resulting in stricture as well as management based on the site and length of urethral stricture. Associated injuries and results are discussed. RESULTS: Of the 5 girls who presented with stricture 4 had undergone suprapubic cystostomy as initial treatment, whereas in 1 primary repair had failed. Urethral reconstruction using a bladder flap tube and distal urethrotomy into the vagina were performed in 3 and 1 cases, respectively. These 4 girls were continent although 1 required clean intermittent catheterization for a short period. The 3 patients with complete urethral loss had a more severe degree of pelvic fracture, including 1 treated with core through internal urethrotomy. CONCLUSIONS: Posttraumatic urethral injury accompanying pelvic fracture in young girls results in challenging management situations. More severely displaced pelvic fracture is associated with greater urethral loss and requires more complex repair. Cases of partial urethral injury or urethral transection without much displacement are better managed by primary repair of the transected urethra, which decreases morbidity. Primary repair may not be feasible in patients with extensive injury, who should be treated with secondary appropriate reconstruction after preliminary suprapubic cystostomy. Complete urethral loss may be managed by bladder flap tube neourethra creations with effective continence and excellent outcomes. Short segment distal urethral strictures may be treated with meatotomy or core through internal urethrotomy.     

电子膀胱软镜在后尿道狭窄（闭锁）患者中的临床应用与价值

目的：探讨电子膀胱尿道软镜在后尿道狭窄（闭锁）患者的临床应用与价值,为手术治疗提供客观依据。方法：总结2009年7月~2010年12月收治98例后尿道狭窄（闭锁）患者的电子膀胱尿道软镜检查资料。结果：98例患者后尿道狭窄（闭锁）长度为1．5～7．0cm,术中发现尿道假道6例,尿道直肠瘘6例,后尿道结石患者19例,狭窄段接近前列腺者26例,后尿道完全闭锁者22例。结论：电子膀胱尿道软镜具有可弯曲,创伤小,无视野盲区,可以方便的观察患者后尿道的情况,为选择手术方式及手术中的具体操作提供可靠的依据。