游离口腔黏膜代尿道治疗尿道下裂及前尿道狭窄50例

目的 探讨口腔黏膜游离移植,治疗严重尿道下裂和长段前尿道狭窄的手术适应证及疗效.方法 2006年5月至2010年4月期间我科共进行口腔黏膜游离代尿道治疗严重尿道下裂及长段前尿道狭窄50例,年龄5-48岁.其中尿道下裂28例,有过一次手术史15例,多次手术史10例.前尿道狭窄22例,狭窄段4～7cm长.结果 28例尿道下裂患者,26例成功;22例尿道狭窄患者,20例成功,手术成功率92.00%(46/50),尿道下裂患者术后阴茎外观满意,尿道开口于阴茎前端,排尿通畅.尿道狭窄患者术后1个月最大尿流率为14～40ml/s,平均29ml/s.所有手术成功患者术后随访1～10个月无尿道狭窄,无尿瘘.尿道下裂和尿道狭窄患者中各有2例失败,术后出现阴茎皮肤切口感染发生尿瘘,6个月行补瘘手术治愈.结论 对于多次手术,局部组织缺乏的尿道下裂及长段前尿道狭窄,应用口腔黏膜游离移植修复尿道,手术疗效好,值得推广.     

经尿道前列腺电切相关前尿道狭窄

经尿道前列腺电切（transurethral resection of the prostate,TURP）术后前尿道狭窄是临床中常见的尿道狭窄,本文对TURP术后前尿道狭窄流行病学、病因学、处理策略以及预防等进行总结分析。TURP术后前尿道狭窄的常见部位是舟状窝、阴茎阴囊交界处、尿道球部。TURP术后前尿道狭窄的可能的病因包括机械损伤、电损伤、感染和留置尿管等。TURP术后前尿道狭窄的治疗一般包括内镜下微创治疗和开放重建手术。内镜下微创治疗的效果无法保证,尤其是对于长段或严重狭窄的患者,狭窄复发率很高。尿道成形手术包括端端吻合、口腔黏膜修复、会阴区皮瓣修复和尿道会阴造口等术式。针对TURP术后前尿道狭窄的相关基础和临床研究均较为匮乏,面对临床上的具体病例,往往是在尿道狭窄处理原则的基础上制定个体化诊疗方案。     

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。     

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.     

结肠黏膜重建尿道治疗复杂性超长段尿道狭窄

目的:探讨结肠黏膜重建尿道治疗复杂性超长段尿道狭窄的应用价值与疗效.方法:对既往已有平均2.5次不成功的尿道修复史的35例患者,采用结肠黏膜一期尿道成形术,治疗其复杂性超长段尿道狭窄.所用结肠黏膜重建的尿道长10～20cm,平均14.6cm.术后分别行尿道造影,检测尿流率,部分患者行尿道镜检查.结果:患者术后随访3～60个月,平均28.5个月.31例术后排尿通畅,最大尿流率大于15 ml/s.1例因结肠黏膜新尿道与前列腺部尿道吻合区血供较差,术后继发尿道狭窄;1例在术后3个月并发尿道外口狭窄,经手术矫正后排尿通畅;2例分别在术后46,20个月时发生与重建尿道无关的球膜部尿道狭窄,采用口腔黏膜尿道成形术后排尿通畅.结论:利用结肠黏膜重建尿道治疗复杂性超长段尿道狭窄或闭锁,是一种可行而有效的方法,尤其是适合在较多常规方法治疗失败者.     

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.     

前尿道替代膜部尿道治疗男性后尿道狭窄52例报告

目的：探讨长段后尿道狭窄手术治疗方法。方法：同顾性总结前尿道替代膜部尿道端端吻合治疗狭窄段〉2cm的后尿道狭窄患者52例。结果：一次手术成功49例,成功率94．2％,3例术后尿线细,排尿不畅经内窥镜切除0．3～0．5cm瘢痕后排尿通畅。随访5～20年,全部排尿通畅,最大尿流率20～25ml／s,平均22ml／s。结论：切除狭窄段瘢痕前尿道替代膜部尿道端一端吻合治疗后尿道狭窄成功率高,远期效果好。术中彻底切除瘢痕,满意的无张力外翻端一端吻合及术后预防感染是手术成功的关键。     

游离阴茎皮片联合口腔黏膜一期治疗18例前尿道狭窄

目的评估游离阴茎皮片背侧移植联合口腔黏膜腹侧覆盖治疗前尿道狭窄的临床疗效。方法回顾性分析2018年1月至2020年7月采用游离阴茎皮片结合口腔黏膜扩大尿道成形术治疗阴茎皮肤不充裕前尿道狭窄患者18例的病例资料。正中纵行切开狭窄段尿道的腹侧和背侧,再将游离阴茎皮片修补尿道背侧缺损、游离口腔黏膜覆盖修补腹侧缺损,留置F16/18硅胶尿管4周后拔除尿管并行尿流率检查。结果 18例患者术后平均随访16.6(6～31)个月,游离阴茎皮片长度为(5.9±2.0)cm,口腔黏膜(唇黏膜16例、舌黏膜2例)取材长度平均(6.4±2.0)cm。术后6个月平均最大尿流率19.8mL/s。术后未见局部皮肤坏死、未发生任何尿瘘,1例再狭窄患者膀胱镜检查发现远端吻合口狭窄,行4次尿道扩张治疗后恢复正常排尿。结论对于局部阴茎皮肤不充裕的长段前尿道狭窄患者,联合游离阴茎皮片背侧移植和口腔黏膜腹侧覆盖是治疗其较为合适的方法。     

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。     

外伤性尿道狭窄外科处理的临床分析（附112例报告）

目的 探讨外伤性尿道狭窄的最佳手术方法,提高疗效.方法 采用尿道（冷刀）内切开术治疗尿道狭窄97例,采用尿道狭窄段切除端-端吻合术治疗尿道狭窄15例.结果 97例经尿道内切开治疗者手术成功率100％,15例尿道狭窄切除端-端吻合治疗者手术成功率93.3％.结论 对单纯尿道狭窄和可引导复杂性尿道狭窄,应首选尿道（冷刀）内切开术.尿道狭窄段切除端-端吻合术仍是复杂性尿道狭窄的可靠术式.     

超长段尿道狭窄术后勃起功能的评估

目的 探讨自体组织替代治疗超长段尿道狭窄对勃起功能的影响.方法 回顾性分析2007年1月至2009年1月采用不同自体组织补片(阴囊纵隔、包皮内板、口腔黏膜)Onlay术式替代治疗超长段男性尿道狭窄患者的临床资料,并随访患者ⅡEF-5评分、QOL评分及最大尿流率,并与术前相应情况进行分析.结果 根据研究标准收集23份有效数据.患者术前及术后3、6、12个月QOL评分分别为5.22±0.75、1.22±1.40、1.82±1.17、2.07±0.46,最大尿流率分别为(3.93±3.62)、(22.46±4.65)、(23.81±6.22)、(21.52±7.44)ml/s,术后不同时期均较术前明显改善(P＜0.01).术前及术后3、6、12个月ⅡEF-5评分分别为14.47±9.55、14.70±5.32、14.26±3.29和14.58±3.62,组间比较差异无统计学意义(P＞0.05).9例狭窄部位累及至后尿道者术后3、6、12个月ⅡEF-5评分分别为11.67±2.59、12.35±1.83、13.19±1.67,14例单纯前尿道狭窄者分别为17.79±6.42、16.57±4.78、16.01±3.85,2组间比较差异均有统计学意义(P＜0.05).狭窄累及后尿道患者多元线性回归分析中,年龄、受伤时间及尿道狭窄段长度与替代术后ⅡEF-5评分呈多元线性相关.结论 自体组织替代治疗男性超长段尿道狭窄对勃起功能影响不明显;狭窄段累及后尿道时可能对患者勃起功能产生一定影响.患者年龄和受伤时间对勃起功能有协同影响作用.

Abstract：

Objective To investigate the effect of substitutive reconstruction of long urethral stricture on male erectile function. Methods From January 2007 to January 2009, 23 patients with anterior or posterior long urethral stricture were accepted for a variety of onlay substitutive procedures, including lingual mucosa, perputial skin, and mid-scrotal skin. During the follow-up, data from the International Index of Erectile Function-5 (ⅡEF-5) questionnaire and the Quality of Life (QOL) questionnaire as well as maximal flow rate were recorded. All data were compared with those obtained before surgery. Results Significant improvement in QOL (1.22 ± 1.40, 1.82 ± 1. 17,2.07± 0.46) and maximal flow rate (22.46± 4.65, 23.81 ± 6.22, 21.52 ±7.44 ) could be observed 3, 6 and 12 months after surgery compared with those before surgery (5. 22 ± 0. 75, 3. 93 ± 3. 62)(P＜0.01). No significant differences in the responses to the ⅡEF-5 questionnaire were observed among all patients during the follow-up (P＞0. 05). At the 3, 6 and 12 months after procedure,scores of ⅡEF-5 in patients with anterior urethral stricture ( 17.79 ± 6.42, 16. 57 ± 4. 78, 16.01 ±3.85) were significantly higher than those with posterior urethral stricture (11.67 ± 2.59, 12.35 ±1.83,13. 19±1.67, P＜0.05). In patients with posterior urethral stricture, the multiple linear regression showed that age, time interval of injury and length of stricture were related to the ⅡEF-5score (P＜0.05). Conclusions Substitutive reconstruction for treating the long urethral stricture has little effect on male erectile function. But the location of stricture, especially extended to posterior urethra, may have impact on the erectile function.     

超长段尿道狭窄术后勃起功能状况评估

目的探讨自体组织替代治疗男性超长段尿道狭窄对勃起功能的影响。方法回顾性分析2003年1月—2007年1月间23例不同自体组织替代治疗患者的临床资料,并进行IIEF-5评分、QOL评分及最大尿流率的术前与术后随方观察。结果所有患者术后3月、6月随访时的QOL评分、最大尿流率较术前均有明显改善(P<0.01):而IIEF-5的平均评分无明显改变(P>0.05)。狭窄部位累及至后尿道时,患者勃起功能有减弱趋势(P<0.05),同期比较中术后3月、6月随访时狭窄部位累及至后尿道患者的IIEF-5平均值要显著低于单纯前尿道狭窄的患者(P<0.05)。狭窄累及后尿道患者多元线性回归分析中,年龄、受伤时间以及尿道狭窄段的长度与替代术后IIEF-5评分呈现多元线性相关。结论自体组织替代治疗男性超长段尿道狭窄对勃起功能影响不明显:狭窄段累及后尿道时则可能对患者勃起功能产生一定的影响。患者年龄、受伤时间对勃起功能起到协同影响作用。     

尿道狭窄或闭锁的治疗(附154例报告)

目的　提高尿道狭窄或闭锁的治疗效果。　方法　尿道狭窄或闭锁者共 15 4例 ,前尿道狭窄或闭锁 4 0例 ,后尿道狭窄或闭锁 114例 ,发病原因 :外伤性 10 6例 ,炎症性 15例 ,医原性 33例。行开放手术 34例 ,腔内手术 12 0例。　结果　 4 0例前尿道狭窄或闭锁者中行开放手术 18例 ,腔内手术 2 2例 ,均成功。随访 6个月～ 1年 ,均排尿通畅。 114例后尿道狭窄或闭锁者中行开放手术 16例 ,术后排尿通畅者 10例 ,排尿困难或不能排尿者 6例 ,尿道造影显示尿道狭窄 ;腔内手术 98例。术后排尿通畅 92例 ,排尿困难或不能排尿 5例 ,尿道造影显示尿道狭窄。　结论　对前尿道狭窄或闭锁者的治疗 ,开放和腔内手术效果均好 ;后尿道狭窄或闭锁 ,首选腔内手术。     

Substitution urethroplasty using oral mucosa graft for male anterior urethral stricture disease: Current topics and reviews

Male anterior urethral stricture is scarring of the subepithelial tissue of the corpus spongiosum that constricts the urethral lumen, decreasing the urinary stream. Its surgical management is a challenging problem, and has changed dramatically in the past several decades. Open surgical repair using grafts or flaps, called substitution urethroplasty, has become the gold standard procedure for anterior urethral strictures that are not amenable to excision and primary anastomosis. Oral mucosa harvested from the inner cheek (buccal mucosa) is an ideal material, and is most commonly used for substitution urethroplasty, and lingual mucosa harvested from the underside of the tongue has recently emerged as an alternative material with equivalent outcome. Onlay augmentation of oral mucosa graft on the ventral side (ventral onlay) or dorsal side (dorsal onlay, Barbagli procedure) has been widely used for bulbar urethral stricture with comparable success rates. In bulbar urethral strictures containing obliterative or nearly obliterative segments, either a two‐sided dorsal plus ventral onlay (Palminteri technique) or a combination of excision and primary anastomosis and onlay augmentation (augmented anastomotic urethroplasty) are the procedures of choice. Most penile urethral strictures can be repaired in a one‐stage procedure either by dorsal inlay with ventral sagittal urethrotomy (Asopa technique) or dorsolateral onlay with one‐sided urethral dissection (Kulkarni technique); however, staged urethroplasty remains the procedure of choice for complex strictures, including strictures associated with genital lichen sclerosus or failed hypospadias. This article presents an overview of substitution urethroplasty using oral mucosa graft, and reviews current topics.     

New frontiers in urethral reconstruction: injectables and alternative grafts

Contemporary management of anterior urethral strictures requires both endoscopic as well as complex substitution urethroplasty, depending on the nature of the urethral stricture. Recent clinical and experimental studies have explored the possibility of augmenting traditional endoscopic urethral stricture management with anti-fibrotic injectable medications. Additionally, although buccal mucosa remains the gold standard graft for substitution urethroplasty, alternative grafts are necessary for reconstructing particularly complex urethral strictures in which there is insufficient buccal mucosa or in cases where it may be contraindicated. This review summarizes the data of the most promising injectable adjuncts to endoscopic stricture management and explores the alternative grafts available for reconstructing the most challenging urethral strictures. Further research is needed to define which injectable medications and alternative grafts may be best suited for urethral reconstruction in the future.     

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。     

Anterior urethral strictures: a brief review of the current surgical treatment

A review of the recent literature on the surgical management of anterior urethral stricture was performed. The literature was searched via PubMed using the search terms 'urethral stricture' and 'urethroplasty' from 1996 to 2009. The management of anterior urethral strictures is changing rapidly in the sense that the reconstructive procedures have evolved greatly. Penile skin, because of its location and because it is hairless, has been popular and used for a long time. Since the early 1990s, buccal mucosa graft (BMG) was introduced in urethral reconstructive surgery and has become the first choice of most practicing urologists. Recently, there has been an increase in the use of lingual mucosa graft with various doctors reporting easy harvesting and lesser morbidity in comparison to BMG. Also, fibrin glue has recently been used to fix the graft with promising results. With the success of tissue-engineered materials that are still in the experimental phase, the urologist would no longer be limited by the quantity of the graft. These substitutes will also boost the appealing scarless endoscopic urethroplasty. This article provides a brief up-to-date review of the main surgical techniques in the management of anterior urethral stricture disease for the contemporary practicing urologists. Present controversies have been given special emphasis. The possible future techniques and the future of the anterior urethral stricture surgery are also discussed in brief.     

口颊黏膜在尿道重建中的应用

随着尿道重建技术的不断改进,口颊黏膜替代尿道成形术逐渐成为前尿道缺损修复的最佳选择。本文主要对口颊黏膜的优势特点作一介绍,并阐述口颊黏膜替代尿道成形术在前尿道狭窄和尿道下裂中的临床应用和进展。     

结肠粘膜重建尿道的动物实验与临床应用

目的　探讨结肠粘膜代尿道治疗复杂性前尿道长段狭窄或闭锁的可行性。　方法　 6条雌性杂种成年狗在全麻下切开尿道 ,剥离全段尿道粘膜 ,取相等长度的结肠粘膜替代尿道粘膜 ,12周后将狗处死 ,取尿道组织作病理检查。采用结肠粘膜替代尿道一期尿道成形术治疗 1例复杂性前尿道长段狭窄患者 ,术后 3个月分别行逆行尿道造影 ,尿道镜和尿流率检查。　结果　 6条狗移植于尿道的结肠粘膜全部成活 ,部分腺上皮转变为移行上皮细胞。采用结肠粘膜替代尿道的患者术后排尿通畅 ,移植段尿道无狭窄 ,最大尿流率 30ml/s。　结论　结肠粘膜代尿道是治疗复杂性前尿道长段狭窄或闭锁的一种有效方法 ,可用于不适合应用包皮或膀胱粘膜及颊粘膜时的尿道重建     

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.