摘要：
目的 探讨经会阴途径治疗骨盆骨折致后尿道断裂或闭锁的手术方式选择及疗效.方法 回顾性分析1990年1月至2017年1月收治的5 000例骨盆骨折伴后尿道断裂或闭锁患者的临床资料.患者均为男性.年龄18个月～77岁,平均36.6岁.车祸致骨盆挤压伤2 010例,高空坠落致骨盆损伤1 680例,各种车床致骨盆挤压伤1 310例.伴内脏器官损伤2 590例,包括肝、脾破裂920例;下肢骨折或断裂1 200例.急诊行尿道会师治疗2 200例,耻骨上膀胱造瘘2 800例.所有患者术前均行排泄性和逆行尿道造影,562例行尿道超声检查,2 448例行尿道镜检查,204例行尿道MRI检查.狭窄或闭锁段长度1.8 ～8.6 cm,平均4.3 cm.后尿道狭窄(尿道连续性尚存)810例(16.2％);后尿道完全闭锁4 190例(83.8％),其中闭锁段≤3 cm者2 650例(53.0％),闭锁段＞3cm者1 540例(30.8％).伴膀胱结石2 300例,会阴瘘或脓肿290例,假道460例,尿道直肠瘘160例,膀胱颈部开放89例.5 000例手术中,单纯经会阴尿道吻合术1 700例,经会阴切开阴茎中隔尿道吻合术1 302例,经会阴切除耻骨下缘尿道吻合术1 910例,阴囊中隔皮瓣代尿道成形术120例,尿道拖入术20例.结果 术后随访6 ～ 72个月,平均23个月.手术总体成功率(最大尿流率＞15ml/s)为92.2c％(4 608/5 000).单纯经会阴尿道吻合术、经会阴切开阴茎中隔尿道吻合术、经会阴切除耻骨下缘尿道吻合术、经会阴阴囊中隔皮瓣代尿道成形术和尿道拖入术的成功率分别为97％(1 649/1 700)、93％(1 211/1 302)、88％(1 680/1 910)、78％(53/68)和75％ (15/20).后尿道狭窄(尿道连续性尚存)的手术成功率为96％(778/810);闭锁段≤3 cm者为95％ (2 517/2 650),闭锁段＞3 cm者为86％(1 324/1 540).结论 经会阴途径尿道端端吻合术疗效确切,已成为后尿道闭锁的一线治疗方案,尤其适用于狭窄或闭锁段≤3cm者.%Objective To evaluate the outcome of various operative selection for treating posterior urethral stricture via transperineal approach.Methods The clinical data of 5 000 patients with posterior urethral stricture or obstruction from January 1990 to January 2017 were analyzed retrospectively.All patients were male.The age of those patients ranged from 18 months to 77 years old,mean 36.6 years old.Pelvic crush inju.ry caused by car accident occurred in 2010 cases.Falling injury occurred in 1680 cases.Pelvic compressed injury occurred in 1 310 cases.Accompanied visceral damage occurred in 2 590 cases,including the liver and spleen rupture in 920 cases,lower limb fracture in 1 200 cases.2 200 cases accepted urethral realignment under emergency.2 800 cases were treated with pubic cystostomy.All patients were undergone a retrograde and voiding urethrogram.562 patients accepted urethral ultrasongraphy,and 2 448 patients accepted urethroscopy.204 patients accepted MRI examination.The mean stricture length was 4.3 cm,ranged from 1.8 to 8.6 cm.Posterior urethral stricture was found in 810(16.2％)cases.The complete olstruction of posterior urethra was found in 4 190 (83.8％) cases,of which the length of the distraction defects≤3 cm was found in 2 650(53.0％) cases and the length of the distraction defects ＞ 3 cm was found in 1 540 (30.8％) cases.Bladder calculi was found in 2 300 cases.The perineal fistula or abscess was noticed in 290 cases.False passage was found in 460 cases.Urethra rectum fistula was found in 160 cases.Bladder neck open was noticed in 89 cases.Repairing was performed via a simple anastomosis after urethral mobilization in 1 700 patients,via separation of the corporeal bodies in 1 302 patients,via separation of the corporeal bodies and inferior pubectomy in 1 910 patients and via scrotal skin flap urethroplasty in 68 patients.Pull-through operation was performed in 20 patients.Results Postoperative follow-up were conducted from 6 to 72 months with average duration of 23 months.The overall successive results after operation was 92.2％(4 608/5 000),which the Q was more than 15 ml/s.The successive rate of urethroplasty were 97％(1 649/1 700) in simple anastomosis;93％ (1 211/1 302) in separation of the corporeal bodies;88％ (1 680/1 910) in separation of the corporeal bodies and inferior puberctomy;78％ (53/68) in scrotal skin flap urethroplasty and 83％ (15/18) in pull-through operation.The successive rate were 96％ (778/810) in posterior urethral stricture;95％ (2 517/2 650)in distraction with the length of obstruction less than 3 cm and 86％ (1 324/1 540) in distraction with the length of obstruction more than 3 cm.Conclusions The transperineal end to end anastomotic urethroplasty has become the first-line therapy for posterior urethral atresia.The length of the strictures or distraction defect which is lower than 3 cm is much more successfully corrected.
