改良带蒂包皮瓣法分期治疗重度尿道下裂的疗效分析

摘要

目的 探讨改良带蒂包皮瓣法分期治疗重度尿道下裂的效果.方法 回顾性分析2015年1月至2016年12月我院运用带蒂包皮瓣预设尿道板的方法分期治疗41例重度尿道下裂患者的临床资料,其中23例采用改良法,为改良组,即在一期手术中离断尿道板后利用远端尿道板纵切卷管(TIP)成形术,完全伸直阴茎后用带蒂包皮瓣预设阴茎体部的尿道板;18例采用传统法,为传统组,即在离断尿道板伸直阴茎后将带蒂包皮瓣运用Bracka法预设尿道板.两组均在一期手术后至少6个月行二期手术,行相应缺失段的尿道成形术.改良组年龄9～18个月,中位年龄13个月;术前尿道开口于阴茎干10例,阴茎阴囊交界处12例,会阴部1例.传统组年龄8～18个月,中位年龄12个月;术前尿道开口于阴茎干6例,阴茎阴囊交界处10例,会阴部2例.两组年龄、尿道开口位置的差异均无统计学意义(P＞0.05).结果 一期手术中改良组修复远端尿道长度(14.5±1.3)mm(13～19 mm),近端尿道长度(3.1±2.4)mm(0 ～6 mm);传统组仅修复近端尿道,长度(5.6±2.9) mm(0 ～9mm).二期手术中测量所需重建的尿道长度,改良组(26.3-±4.4)mm(22 ～34 mm),传统组(40.5±3.3) mm(36 ～43 mm),两组比较差异有统计学意义(P＜0.05).拔除导尿管后出现尿道狭窄3例,改良组2例(2/23,8.6％),传统组1例(1/18,5.6％).术后随访2～3年,平均2.4年.共发生尿道皮肤瘘6例,改良组3例(3/23,13.0％),传统组3例(3/18,16.7％).术后传统组2例出现睾丸回缩.术后随访均未出现尿道狭窄、尿道憩室、阴茎下弯及阴茎隐匿.两组术后总并发症发生率比较差异无统计学意义(P＞0.05).结论 采用改良带蒂包皮瓣法分期治疗重度尿道下裂能充分利用自身材料,二期手术时修复尿道更短,近期术后并发症与传统法相当,是一种安全、可行的方法.%Objective To investigate the effect of a modified preputial flap urethroplasty in twostage treatment of severe hypospadias.Methods The clinical characteristics of the severe hypospadias patients (41 cases) who underwent the staged urethroplasty by using the procedure of preset urethral plate with preputial flap from January 2015 to December 2016 were analyzed retrospectively.We used a modified method (modified group,23 cases):Form the distal urethra with the transected distal urethral plate by using tubularize incised plate (TIP) procedure during the first stage operation,after completely straightened the penis,urethral plate was preseted with transverse preputial flap at the penis shaft.While in the traditional group (18 cases),urethral plate was preseted with preputial flap by using Bracka procedure after transecting urethral plate.The corresponding missing part of urethra underwent urethroplasty at the second stage operation six months later.The patients in the modified group were 9 to 18 months old,and the median age was 13 months;meatus were located at the penis shaft in 10 cases,scrotum in 12 cases,perineum in 1 case.The patients in the traditional group were 9 to 18 months old,and the median age was 13 months;meatus were located at the penis shaft in 6 cases,scrotum in 10 cases,and perineum in 2 cases.There was no statistic difference in age and meatus position between the two groups.Results During the first stage operation,distal urethra was repaired by 13-19 mm,with an average of (14.5 ± 1.3) mm,and the proximal urethra was repaired by 0-6 mm,with an average of (3.1 ± 2.4) mm at the modified group.While at the traditional group,the length of proximal urethra was repaired of 0-9 mm,with an average of (5.6:±:2.9) mm.The urethral length required for reconstruction was measured during the second stage operation,with an average of (26.3:t:4.4) mm in the modified group and (40.5 ± 3.3) mm in the traditional group (P ＜ 0.05).There were 3 case of urethral stricture after removed the catheter,with 2 cases in the modified group and 1 case in the traditional group.Postoperative follow-up was 2 to 3 years,with an average of 2.4 years.There were 3 cases (3/23,13.0％) of urethral fistula in the modified group and 3 cases (3/18,16.7％) in the traditional group.Ascended testis occured in 2 patients in the traditional group after operation.No case of urethrostenosis,diverticulum,chordee or concealed pennis was recorded.There was no significant difference in postoperative complications between the two groups (P ＞ 0.05).Conclusions The modified staged preputial flap method shorten the new forming urethra by making full use of its own materials at the second stage operation,which was helpful to reduce complications.