445例先天性尿道下裂的治疗

目的 探讨不同术式对445例不同类型先天性尿道下裂患儿的手术治疗效果。方法 回顾性分析我院1988年—2003年445例先天性尿道下裂病例资料，其中采用阴茎阴囊纵隔带蒂皮瓣尿道成型术311例，包皮内板带蒂皮瓣尿道成型术52例，包皮及阴茎阴囊联合皮瓣尿道成型术61例，膀胱粘膜代尿道术21例。每例均同时行耻骨上膀胱造瘘术。结果 治愈率90．6％，并发症为9．4％。其中尿道狭窄11例，尿瘘31例。尿道狭窄中膀胱粘膜法1例，包皮内板法2例，阴茎阴囊纵隔法5例，联合皮瓣法3例；尿瘘中膀胱粘膜法1例，包皮内板法3例，阴茎阴囊纵隔法24例，联合皮瓣法3例。结论 根据尿道下裂类型选择不同的术式 尿流改道，并严格遵守整形外科的原则是尿道下裂手术成功的关键。     

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。     

带蒂阴囊包皮联合皮管治疗尿道下裂

目的 探讨带蒂阴囊包皮联合皮管治疗尿道成形，治疗阴囊型和阴茎阴囊型尿道下裂的方法及其疗效。方法 矫正阴茎下曲，切取包皮、阴囊皮瓣、缝合成管状，正位尿道口修复尿道下裂。结果 阴茎阴囊型和阴囊型尿道下裂32例。术后3例感染漏尿，2例修补治愈，1例自行愈合。余一期愈合，均排尿顺利。结论 应用带蒂阴囊包皮管治疗阴囊型及阴茎阴囊型尿道下裂是一种理想方法。     

横裁岛状包皮皮瓣一期修复尿道下裂的经验

目的总结横裁岛状包皮皮瓣法修复先天性尿道下裂的经验。方法对1999年-2005年我科56例采用横裁岛状包皮皮瓣法进行尿道成形的尿道下裂患儿进行回顾性分析。其中5例加用尿道口为基底的阴囊矩形皮瓣作Duplay尿道成形。结果本组病例均获随访,时间3个月-4年,阴茎外观良好,阴茎下弯矫正满意,排尿通畅。一次手术成功49例,占89．3％;术后尿瘘5例,经第二次手术修补后痊愈,尿道狭窄1例,经尿道扩张后排尿改善。结论横裁岛状包皮皮瓣符合阴茎皮肤的解剖生理特点,设计合理,采用吻合口连续缝合,更加降低了尿瘘的发生率,避免耻骨上造瘘及带来的膀胱损伤。对多数尿道下裂尤其是有阴茎下弯的尿道下裂,采用横裁包皮岛状皮瓣法并灵活加用尿道口基底矩形皮瓣是一个很好的选择。     

Duckett术治疗尿道下裂临床分析

198 0年Ｄｕｃｋｅｔｔ[1] 报道利用带蒂横形包皮内板尿道成形术治疗尿道下裂以来 ,已被广泛的采用 ,我院于 1993～1999年采用此术式一期治疗各型尿道下裂 5 6例 ,术后效果较满意。1.临床资料　本组 5 6例均为男性 ,年龄 3～ 7岁 ,其中阴茎体型 38例 ;阴茎阴囊型 17例 ;会阴型 1例。全部病例阴茎下弯矫正及尿道成形一期完成。2 .手术要点　①矫正阴茎下弯 ;②裁取带蒂岛状皮瓣 ,皮瓣比尿道缺损长0 .5～ 1.0ｃｍ ,宽 1.5ｃｍ。分离过程中注意保护浅层和深层血管及其间膜状组织 ;③皮管缝合与尿道吻合。在修剪无浅筋膜浅层的皮瓣周边后 ,围绕…     

重度尿道下裂的手术修复

介绍在重度尿道下裂修复中Ｄｕｃｋｅｔｔ＋Ｄｕｐｌａｙ手术的应用方法及特点。方法；对阴茎下弯矫正后，尿道缺损长的重度尿道下裂病例采用尿道口附近阴囊皮肤作Ｄｕｐｌａｙ尿道成形，再与Ｄｕｃｋｅｔｔ岛状皮瓣所作皮管吻合的联合手术方法，共修复重度尿道下裂４２例，平均年龄２．９岁，术后随访６个月－３年。结果；４２例中，一次手术成功３２例，８例尿瘘，１例尿道狭窄，１例成形尿道呈憩室状扩张。     

阴茎阴囊皮瓣翻转埋藏法治疗各型尿道下裂的改进

目的：探讨保留尿道板与翻转阴茎阴囊皮瓣或皮管形成尿道法治疗各型尿道下裂的效果。方法：对我院１９８４年前采用的单纯阴茎阴囊皮瓣埋藏法进行改进，包括保留尿道板并与翻转阴茎阴囊皮瓣或皮管形成尿道，保证尿道正位开口，伴阴茎阴囊转位者一期矫正，取消膀胱造瘘等。结果：用改进术式治疗各型小儿尿道下裂３１２例，一期成功２６６例（８５．３％），因尿瘘、尿道狭窄等手术失败４６例（１４．７％）。结论：改进后的保留尿道板并与翻转之阴茎阴囊皮瓣或皮管形成尿道法是治疗本病较理想的方法，支架管替代膀胱造瘘和同时矫正阴茎阴囊转位不但简化了手术步骤，而且有利于手术一期成功     

阴囊中缝带蒂皮瓣治疗尿道下裂的临床应用体会

目的 探讨带蒂阴囊中缝带蒂皮瓣转移覆盖技术在治疗尿道下裂病例多次手术后皮肤缺损中的适应证与疗效.方法 2014年2月至2015年1月,收集我院12例患儿,年龄5～15岁,平均8.4岁.均为外院多次尿道下裂术后失败患儿.为再次治疗入我院.所有患儿均接受口腔黏膜镶嵌尿道成形术一次完成手术.完成尿道重塑后,在阴囊皮肤血供解剖学的基础上,对于重度尿道下裂患儿经多次术后皮瓣遭严重破坏而不足的患儿,采用阴囊中缝皮瓣游离,转移覆盖于阴茎腹侧创面皮肤缺损处.结果 术后随访6～12个月,平均8.3个月,12例患儿全部获得随访,所有患儿皮瓣完全成活,无尿道瘘及尿道憩室,术后2周出现尿道狭窄1例.接受会阴尿道镜检查,确定为口腔黏膜与原尿道吻合口狭窄,扩张后治愈.长期随访患儿阴茎下弯矫正满意,尿道外口位于阴茎头正位,排尿通畅,无尿道瘘、尿道狭窄、尿道憩室等.阴茎及阴囊外观满意.结论 对于接受多次尿道下裂修补术后需要重新接受手术的患儿,由于多次手术对阴茎皮瓣破坏严重,再次行尿道下裂修补术时,我们选择游离带蒂阴囊中缝皮瓣覆盖新尿道,较传统上阴茎阴囊皮肤覆盖新尿道的张力较低,覆盖范围广并避免了皮肤的臃肿感.该手术方法简单,操作难度不高,成功率高,术后并发症少,外形美观,值得临床推广应用.     

阴囊纵隔带蒂皮瓣Ⅰ期修复尿道下裂

尿道下裂是常见的泌尿系先天性畸形,修复方法约200余种。我院自1990年以来采用阴囊纵隔带蒂皮瓣Ⅰ期修复尿道下裂24例,疗效满意,现报告如下。 临床资料本组24例,年龄4～14a,平均7.5a。阴囊均发育良好,阴茎型8例,阴茎阴囊16例。修复长度2～5cm,平均4cm。出院时一期手术成功修复21例,并尿瘘2例,尿道外口狭窄1例,再手术后治愈。 手术方法氯胺酮全麻或持续硬膜外麻醉下,阴茎头缝牵引线。距冠状沟0.5 cm处环形切口,于Buck筋膜浅层向阴茎根部剥离包皮,切除腹侧及尿道旁的纤维索带,彻底矫正阴茎下曲。测量尿道缺损长度,从阴囊纵隔切取矩形阴囊带蒂皮瓣,宽度1.5～2.0 cm,长度2～6cm,瓣长一般至正位开口再多取0.5cm,不应有张力。同侧阴囊皮肤按原设计线切开至肉膜,仔细分离到阴囊隔,以同法做对侧切口,将阴囊隔血管蒂皮瓣提起,对光相视可清晰看见隔内血管丛。     

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.     

Outcome analysis of tubularized incised urethral plate using dorsal dartos flap for proximal penile hypospadias repair

PurposeTo assess the outcome of tubularized incised plate (TIP) urethroplasty in conjunction with a dorsal dartos flap for primary proximal penile hypospadias.Materials and methodsForty-nine patients with proximal penile hypospadias underwent a one-stage TIP urethroplasty with single-layer closure using polyglactin suture. A dorsal dartos (subcutaneous) flap, harvested from the dorsal penile shaft was used to cover the neourethra ventrally. Glanuloplasty was also performed in all cases. All patients had a well preserved urethral plate after straightening of the penis. Complications and cosmetic appearance were documented during follow-up.ResultsMean patient age at surgery was 23 months (16–72 months). Mean operative time was 180 min (154–240 min). At the mean follow-up of 36 months, the overall complication rate was 12% (4 fistulae, 1 meatal stenosis). Glandular dehiscence occurred in one patient, and 38 patients (78%) required dorsal Nesbit plication. No patient had residual chordee, neourethral stricture or a urethral diverticulum, and the neomeatus with a slit-like appearance was positioned at the glans tip.ConclusionsTIP urethroplasty with dorsal dartos layer covering the neourethra is an effective treatment for primary proximal penile hypospadias with a preserved urethral plate and without severe curvature. There is a good cosmetic outcome with low risk of complications.     

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     

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。     

One-stage repair of severe hypospadias using modified tubularized transverse preputial island flap with V-incision suture

PurposeAlthough hypospadias repair for preserving the urethral plate is popular among pediatric urologists, applying this procedure to severe hypospadias is controversial. We report the outcome of applying additional modifications to the modified tubularized transverse preputial island flap (TPIF) procedure reported previously [Patel RP, Shukla AR, Austin JC and Canning DA. Modified tubularized transverse preputial island flap repair for severe proximal hypospadias. BJU Int 2005;95:901–4] for repairing severe hypospadias.Materials and methodsWe retrospectively evaluated our series of 22 patients (mean age 17.5 months) who underwent the modified TPIF with an additional simple modification of meatoplasty with V-incision suture. Patients were followed for a mean period of 18 months.ResultsAfter releasing the chordee, the hypospadiac orifice was retracted to become penile in five patients (22.7%), penoscrotal in six (27.3%), scrotal in nine (40.9%), and perineal in two (9.1%). The median length of the neourethra was 46 mm. One-stage repair was successful in 19 patients (86.4%) without any complications.ConclusionOur modified TPIF procedure yielded favorable outcomes functionally and cosmetically with a low postoperative morbidity rate. Such a procedure can be considered useful for repairing severe hypospadias when the urethral plate cannot be preserved.     

尿道口基底两侧包皮瓣Ⅰ期尿道成形术修复近端型尿道下裂

目的 探讨尿道口基底两侧包皮瓣Ⅰ期尿道成形术修复近端型尿道下裂的临床效果.方法 本组53例,年龄为4.5(2～13)岁.采用尿道口基底两侧和背部的包皮瓣与尿道板联合卷管成形新尿道.结果 其皮瓣长度平均为4.1(2.5～9.0)cm.术后尿液引流时间平均10.9 d(7～14 d).37例获随访6个月以上.Ⅰ期手术成功44例(83.0%).并发症:尿瘘6例,尿道狭窄2例,尿道憩室1例均需再次手术.尿道外口狭窄1例经尿道扩张后治愈.再次手术成功率为77.8%(7/9).随访:外观佳的占86.5%(32/37);梗阻型尿流曲线为:35.5%(11/31).结论 该术式符合解剖生理,对Ⅰ期修复近端型尿道下裂是一种较理想的手术方式.

Abstract：

Objective To report the of treatment of proximal hypospadias with one-stage urethroplaty with two laterally-based flaps. Methods Fifty-three patients (mean age, 4. 5 years; age range:2-13 years) with hypospadias and severe chordee were operated. Neourethra was formed with tabularized meatal based paracoronal skin flaps and urethral plate. The neourethral flap was 2.5-9 cm (mean 4. 1 cm) in length. The catheters were removed 7-14 days (mean 10. 8 days) post-operately.Thirty-seven patients were followed up more than 6 months. Results Successful one-stage repair was achieved in 44 cases (83. 0%). Fistula developed in 6 patients, urethral stricture in 2 patients, urethral diverticulum in 1 patient which required re-operation. Meatal stenosis developed in 1 patient. The reoperation success rates were 77. 8% (7/9). Good post-operative cosmetic appearance of penis was achieved in 86. 5% of patients (32/37). A plateau uroflow curve (vs normal bell curve) was observed in 35. 5% (11/31) of patients. Conclusions The technque was based on the applied anatomy. It offers a good alternative for proximal hypospadias.     

Autologous in vitro cultured urothelium in hypospadias repair

ObjectiveTo treat severe hypospadias with a transplant of autologous in vitro cultured urothelial cells on acellular dermis.Patients and methodsDuring 2000–2002 six patients aged 14–44 months with severe hypospadias were treated surgically with autologous urothelial cell transplants. All were born with scrotal or perineal hypospadias and pronounced chordee. All patients were subjected to a two-staged procedure starting with repair of the chordee. Urothelial cell harvesting via bladder lavage was performed during the first operation. The neourethra was constructed by using a transplant with cultured urothelium in an on-lay fashion. Patients have been followed 3–5.5 years.ResultsAll six boys are voiding through their neourethra without straining and have no residual urine after micturition. Five patients are using a standing voiding position and present bell shaped, urinary flow curves. One developed a stricture treated conservatively with persisting good effect (after more than 5 years). Two developed a fistula requiring surgical correction that was uneventful. The last patient developed an obstruction in the proximal anastomosis that was treated with an internal urethrotomy. Cosmetic appearance is good in all cases with good parental satisfaction. Urethroscopy in all patients show a wide penile neourethra. Biopsies indicate a mucosal lining consisting of urothelial cells in three cases.ConclusionThis technique is feasible for treatment of a selected group of hypospadias where pronounced chordee and shortage of preputial and penile skin complicates the creation of a neourethra. It may have other clinical implications including disorders such as bladder exstrophy and cloacal malformations, as well as mutilating traumatic injuries or cancer therapy.     

The extended Mathieu procedure in coronal,distal penile,and midshaft hypospadias repair

The Mathieu procedure was adequately modified for glanular, coronal, and midshaft hypospadias variants with chordee and/or urethral hypoplasia in order to anatomically reconstruct the penis. A total of 129 patients aged 12 months to 22 years with coronal (35.7%), distal penile (51.9%), and midshaft (12.4%) hypospadias were operated upon. Chordee was found in 33.3% and distal urethral hypoplasia in 15.5% of the patients. The ventral flap was based anatomically on the external meatus, the glans was made pyramidal with an apical external meatus, the prepuce was resutured, and the neurethra was buried deeply within the glans. In patients with distal urethral hypoplasia the external meatus was incised proximally; in chordee the urethral plate was mobilized off the corpora cavernosa. Fistulas were uncommon (3.4%) in the primarily operated patients. The external meatus was always apical, and no stenosis was demonstrated at follow-up. The prepuce was reconstructed in 71.5% of patients. The extended Mathieu procedure appears recommendable for all coronal, distal penile, and midshaft variants regardless of associated anomalies of the penis. It also seems suitable for secondary repairs. The prepuce can be reconstructed in the majority of patients. The complication rate is significantly low compared to other methods, and the extended Mathieu operation is a good teaching tool with a high success rate and versatility.