阴囊纵隔皮瓣尿道成形术治疗长段前尿道狭窄

目的 总结阴囊纵隔皮瓣尿道成形术治疗长段前尿道狭窄的手术经验.方法 本组41例患者,年龄17～76岁,平均42.7岁,病程4～38个月,平均15个月.术前经逆行尿道造影、排泄性膀胱尿道造影均证实前尿道狭窄.狭窄段长度3cm～7cm,平均4.1 cm.术前27例尿流率测定均为低平曲线,最大尿流率3.5～6.9 ml/s,平均5.7 ml/s.运用阴囊纵隔皮瓣尿道成形术治疗长段前尿道狭窄.结果 41例患者随访12～36个月,平均23.1个月.术后排尿通畅39例,测定最大尿流率16～36ml/s,平均17.2 ml/s.出现并发症4例,其中尿道狭窄2例,尿道毛石形成2例,本组无尿瘘发生.结论 运用阴囊纵隔皮瓣尿道成形术治疗长段前尿道狭窄,手术成功率高,并发症少,是治疗长段前尿道狭窄的良好术式.     

尿道切开一期成形术治疗前尿道长段狭窄

自 1995年 5月至 2 0 0 0年 8月 ,我们采用狭窄段切开一期成形术治疗男性前尿道长段狭窄 10例 ,效果满意。现报告如下。材料与方法　本组 10例。年龄 31～ 79岁。其中有尿道炎病史者 3例 ,留置导尿史者 6例 ,排尿困难 >3年者 3例 ,>5年者 2例 ,>10年者 5例。 9例排尿时狭窄段近端尿道有膨胀感 ,有尿潴留史 3例。查体 :狭窄段尿道呈条索状 ,质硬。 2例尿道外口呈针孔样 ,尿道外口凹陷 ,试行尿道扩张 ,均不能通过12F尿道探子。逆行尿道造影显示狭窄段 4～ 8cm ,IVU示有双肾积水 3例 ,继发膀胱结石 3例。尿常规检查白细胞增多 6例。10例尿细…     

尿道背侧颊黏膜镶嵌补片法治疗长段前尿道狭窄

目的 评价颊黏膜尿道背侧镶嵌技术尿道修复重建手术的有效性和安全性.方法 男性前尿道狭窄患者57例.平均年龄36(17～52)岁.尿道狭窄长度平均3.0(2.5～7.0)cm.颊黏膜取材长度平均4.0(3.5～8.0)cm,平均宽度2.3(I.8～2.5)am.57例均有经尿道内窥镜冷切电切手术史,其中1次手术史29例(51%),2次20例(35%),3次8例(14%),行耻骨上膀胱造瘘48例,9例采用尿道扩张维持.手术游离并旋转尿道,并于尿道背侧纵行切开,6-0可吸收线缝合颊黏膜与尿道切缘.保留尿管4周,拔管时行顺行尿道造影.患者排尿困难和尿线变细、尿道造影或尿道镜发现尿道管腔狭窄<16 F确定为尿道狭窄复发.结果 57例手术均成功,平均手术时间135(105150)min.平均随访11.2(1～23)个月.尿道通畅54例(95%),术后2～3个月复发3例(5%),狭窄部位均为远端的颊黏膜与尿道结合部,行尿道内窥镜冷刀切开,定期尿道扩张治疗.伤口感染3例,未发生尿瘘及尿道憩室.患者口腔疼痛持续2～5 d,平均2.3 d.术后无张VI困难、颊部麻木及腮腺导管梗阻等并发症发生,VI腔颊部均未见瘢痕形成.结论 VI腔颊黏膜尿道背侧镶嵌补片修复重建尿道,效果确切、并发症少、狭窄复发率低,是理想的长段前尿道狭窄的修复重建手段.     

阴茎带蒂皮瓣扩大尿道Ⅰ期治疗长段阴茎部尿道狭窄

长段阴茎部尿道狭窄不适合行尿道内切开术或狭窄段切除、尿道端端吻合术，对于这些病例的手术方法尚无一致意见。自1998年5月～2003年4月，我院施行狭窄段尿道剖开，阴茎局部带蒂皮瓣内翻与剖开的尿道缝合以扩大尿道内腔，治疗长段阴茎部尿道狭窄7例，取得良好效果，现报告如下。     

睾丸鞘膜补片非管状化尿道成形术治疗前尿道长段狭窄的探讨

目的：探讨前尿道长段狭窄的治疗方法。方法：对9例前尿道长段狭窄患者行睾丸鞘膜补片非管状化尿道成形术。结果：本组9例均一次成功,术后3周拔除尿管,平均随访28个月,排尿通畅,阴茎无畸形。结论：睾丸鞘膜可作为良好的尿道替代物,手术创伤小,取材方便,组织修复快,以补片形式非管状化覆盖尿道缺损,可避免鞘膜瓣形成管状而减少成形尿道再狭窄,而且游离鞘膜与带蒂鞘膜移植效果均良好,可减少成形尿道再狭窄,值得推广。     

膀胱粘膜移植治疗长段尿道狭窄

本文报告作者１９８４年１０月至１９９３年１０月为１２例长段尿道狭窄（５例为前尿道狭窄，７例为后尿道狭窄）患者施行膀胱粘膜尿道一期成形术。治愈１０例，好转２例。随访半年至９年无特殊。     

前尿道代后尿道成形术治疗男性复杂性后尿道狭窄

目的探讨长段复杂性后尿道狭窄治疗新方法。方法采用分期前尿道代后尿道成形术治疗3例复杂性后尿道长段狭窄（6．5—10．0cm）患者。第一期行阴茎转位尿道端端吻合术，术后3—6个月行二期阴茎伸直、尿道会阴造口术，6个月后行第三期前尿道成形术（Johanson Ⅱ期尿道成形术）。结果例1术后排尿通畅，膀胱尿道造影检查示尿道通畅，双侧输尿管返流近消失，最大尿流率18．8ml／s，随访2年，最大尿流率18ml／s，无剩余尿。例2术后排尿通畅，最大尿流率19．5ml／s，无剩余尿，尿道扩张可顺利通过22F尿道探子。例3经会阴一耻骨联合径路行第一期阴茎转位尿道端端吻合术、尿道直肠瘘、尿道会阴瘘切除、修补术，术后尿道直肠瘘及尿道会阴瘘治愈，但因耻骨联合切口感染致吻合口狭窄，有待进一步治疗。结论分期前尿道代后尿道加前尿道重建方法是治疗男性长段复杂性尿道狭窄的有效方法。     

尿道狭窄和尿道成形术的相关问题

尿道重建手术成功率的高低与多种因素有关,复杂性尿道成形手术技巧的掌握需要多年经验的积累与总结。本文对尿道狭窄的各种检查．包括影像学、膀胱尿道造影和体检,手术时机和患者的选择,前、后尿道成形术的关键等相关问题作一论述。     

阴囊带蒂皮瓣尿道成形术治疗复杂性尿道狭窄13例报道

复杂性尿道狭窄多指尿道狭窄段〉3.0cm,且因多次手术,加上膀胱尿道感染及多处窦道形成尿瘘且合并感染者,手术困难。为进一步提高疗效,探讨更为适宜的治疗方法,我们采用带蒂阴囊皮瓣尿道成形术,用以治疗复杂性尿道狭窄,效果满意。报告如下。     

Incidence,Causes, and Complications of Urethral Stricture Disease

Urethral stricture refers to any narrowing of the urethra, independent of whether it affects the flow of urine out of the bladder. Urethral stricture occurs mainly in men, and the disease is a common and challenging urologic condition. The real incidence of male urethral stricture disease remains unknown, and worldwide differences have been observed based on geography, population, and mean country income. The number of patients with urethral strictures climbs sharply after 55 yr of age in the Western population. The main causes of urethral strictures consist of congenital anomalies of the mucosal membrane, infection, traumatic scarring after blunt pelviperineal trauma, urethral instrumentation, catheterisation, hypospadias failures, and inflammatory disease of the corpus spongiosum caused by lichen sclerosus. Idiopathic and iatrogenic aetiology are the main causes of urethral strictures in developed countries. Trauma remains the most common aetiology of urethral strictures in developing and Third World countries. About 90% of men with urethral stricture disease present complications. The management of urethral stricture disease may result in complications. The main direct complications of urethral surgery are bleeding, infection, incontinence, impotence, and stricture recurrence.Patient summaryUrethral stricture is a common urologic disease affecting men. Urethral strictures result in lower urinary tract symptoms and affect quality of life. Perineal trauma, long-term urethral catheterisation, urologic instrumentation, chronic inflammatory disorders such as lichen sclerosis, and sexually transmitted diseases are typical causes.     

Treatment of Urethral Stricture Disease by Internal Urethrotomy,Dilation, or Stenting

Management of urethral strictures depends on the characteristics of each individual case and remains a great challenge in reconstructive urology. Treatment of anterior urethral strictures usually starts with minimally invasive procedures, such as urethral dilatation or internal urethrotomy. The popularity of these methods is based on the simple application, the low complication rate, and the fact that most general urologists do not perform open urethroplasty. These methods offer faster recovery, minimal scarring, and fewer infections, although recurrence is always possible. Success depends on adequate vascularity within the underlying spongiosal tissue, which may substantially increase the failure rate. Because the recurrence rate has remained higher than it was in past decades, various modifications of urethral stricture treatment have been suggested, including laser urethrotomy and urethral stents. Since the late 1980s, two different approaches have been studied to prevent scaring contraction: permanent stent versus temporary stents left indwelling for a limited time and then removed. Although the first reports seemed to promise excellent outcomes, longer follow-up began to cast doubt on the usefulness of urethral stenting as a primary treatment modality for urethral stricture disease. The purpose of our study was to evaluate the published literature with respect to any new information on minimally invasive procedures in the treatment of urethral strictures.Patient summaryThe optimal indications for dilatation or internal urethrotomy are simple bulbar strictures <2 cm without spongiofibrosis or history of previous treatment. Recurrent urethral strictures after repeated interventions are usually more complex and can render the definite open urethral surgery more difficult.     

Management of Urethral Stent Failure for Recurrent Anterior Urethral Strictures

Background

Urethral stent placement for recurrent anterior urethral strictures may cause restenosis and complications.

Objective

To describe our experience with patients who had restenoses and complications following urethral stent placement for the treatment of recurrent anterior urethral strictures.

Design, setting, and participants

We evaluated retrospectively the records of 13 men with anterior urethral stricture who experienced restenosis and complications after stent insertion. We recorded stent position, prestent and poststent urethral procedures, restenosis location, stent-related complications, and management of stent failures.

Surgical procedure

The stent was removed en bloc with the whole strictured urethral segment or wire by wire after a ventral or a double-ventral plus dorsal-sagittal urethrotomy and stent section.

Measurements

Successful outcome was defined as standard voiding, without need of any postoperative procedure, and full recovery from complications.

Results and limitations

Four patients did not undergo surgery and the stent was left in situ. Of these patients, two required permanent suprapubic cystostomy. Nine patients underwent challenging surgical stent removal and salvage urethrostomy: After the first stage, three patients are waiting for further reconstructive steps, five elected the urethrostomy as a permanent diversion, and one completed the staged reconstruction using a buccal mucosa graft at the second stage. After surgery, seven of the nine patients (77.8%) were free of strictures and stent-related complications, while a restenosis occurred in two of the nine (22.2%) cases.

Conclusions

The management of urethral stent failure represents a therapeutic challenge. The stent risks converting a simple stenosis into a complex stenosis requiring a staged urethroplasty, a definitive urethrostomy, or a permanent suprapubic diversion.     

A Prospective Patient-centred Evaluation of Urethroplasty for Anterior Urethral Stricture Using a Validated Patient-reported Outcome Measure

Background

Studies of interventions for urethral stricture have inferred patient benefit from clinician-driven outcomes or questionnaires lacking scientifically robust evidence of their measurement properties for men with this disease.

Objective

To evaluate urethral reconstruction from the patients’ perspective using a validated patient-reported outcome measure (PROM).

Design, setting, and participants

Forty-six men with anterior urethral stricture at four UK urology centres completed the PROM before (baseline) and 2 yr after urethroplasty.

Intervention

A psychometrically robust PROM for men with urethral stricture disease.

Outcome measurements and statistical analysis

Lower urinary tract symptoms (LUTS), health status, and treatment satisfaction were measured, and paired t and Wilcoxon matched-pairs tests were used for comparative analysis.

Results and limitations

Thirty-eight men underwent urethroplasty for bulbar stricture and eight for penile stricture. The median (range) follow-up was 25 (20–30) mo. Total LUTS scores (0 = least symptomatic, 24 = most symptomatic) improved from a median of 12 at baseline to 4 at 2 yr (mean [95% confidence interval (CI)] of differences 6.6 [4.2–9.1], p < 0.0001). A total of 33 men (72%) felt their urinary symptoms interfered less with their overall quality of life, 8 (17%) reported no change, and 5 (11%) were worse 2 yr after urethroplasty. Overall, 40 men (87%) remained “satisfied” or “very satisfied” with the outcome of their operation. Health status visual analogue scale scores (100 = best imaginable health, 0 = worst) 2 yr after urethroplasty improved from a mean of 69 at baseline to 79 (mean [95% CI] of differences 10 [2–18], p = 0.018). Health state index scores (1 = full health, 0 = dead) improved from 0.79 at baseline to 0.89 at 2 yr (mean [95% CI] of differences 0.10 [0.02–0.18), p = 0.012]).

Conclusions

This is the first study to prospectively evaluate urethral reconstruction using a validated PROM. Men reported continued relief from symptoms with related improvements in overall health status 2 yr after urethroplasty. These data can be used as a provisional reference point against which urethral surgeons can benchmark their performance.     

Reconstructive Management with Urethroplasty

To answer the question of which surgical technique represents the most efficient procedure for urethral reconstruction, the most common techniques are described. Depending on stricture length, stricture location, and patient history, suitable techniques are presented. Preoperative examination and intraoperative findings, such as the condition of the urethral plate, guide the choice of technique. Excision and primary anastomosis is the technique of choice in post-traumatic and short strictures. Flaps and free transplants are necessary in longer strictures. In cases of destruction of the urethral plate, two-stage urethroplasties using buccal mucosa or skin grafts are necessary. For decision making about the adequate urethroplasty technique, underlying pathophysiology, previous treatments, stricture length and location, and shape of the urethral plate have to be considered.Patient summaryAfter unsuccessful primary treatment of urethral strictures and in long urethral strictures, open urethroplasties represent the gold standard treatment. Several techniques are available. Selecting the optimal technique depends on preoperative diagnostic evaluation and intraoperative findings.     

Reconstructive Management with Buccal Urethroplasty

We present the historical evolution of the use of buccal mucosa in reconstructive surgery, from the first application in ophthalmology to paediatric surgery and, finally, urethral surgery. This process spanned 99 yr, from 1894 to 1993. The harvesting of buccal mucosa from the cheek requires careful preoperative patient evaluation and selection. To avoid postoperative complications related to the harvesting site, we provide some suggestions based on a large series of patients. The use of a one- or two-stage repair procedure in penile urethroplasty is discussed, and some step-by-step surgical techniques are suggested. The reconstruction of the bulbar urethra using buccal mucosa in traumatic and nontraumatic strictures is also discussed, and different techniques are presented. Finally, appraisal and discussion of some challenging topics (eg, evidence for efficacy, complications, implications, worldwide use) concerning the use of buccal mucosa for urethral stricture reconstruction are presented based on the current literature.Patient summaryWe looked at the history and evolution of the use of buccal mucosa for reconstructive urethral surgery and found that harvesting the buccal mucosa from the cheek is a safe procedure. The use of buccal urethroplasty represents the gold standard in the management of patients with anterior urethral strictures.     

等离子体柱状电极联合环状电极腔内治疗男性后尿道狭窄

目的评价经尿道等离子体柱状电极联合环状电极腔内治疗后尿道狭窄的临床疗效。方法2007年9月～2012年9月,采用英国Gyrus公司等离子体柱状电极联合环状电极,腔内治疗24例男性后尿道狭窄。术前狭窄长度9．2～24．3mm,平均13．6mm。术前与术后1、3个月行常规尿道造影及最大尿流率测定,术后12个月行尿道镜检查,评价手术效果。结果术后随访1～21个月,平均13．6月,其中17例〉12个月。术前最大尿流率4．2—9．1ml／s,中位数5．6ml／s,术后最大尿流率16．2～24．5ml／s,中位数17．6ml／s。19例（79．2％）获得成功,无明显尿道梗阻症状,尿道造影或尿道镜检查未发现再狭窄。5例再狭窄,其中1例行开放性尿道成形术,4例定期行尿道扩张。结论经尿道等离子体柱状电极联合环状电极治疗后尿道狭窄,手术操作简单,损伤小,瘢痕组织切除效率高,视野清楚,无严重手术并发症,复发率低,是治疗男性后尿道狭窄的安全有效方法。