复杂性尿道下裂修复失败后的治疗

Treatment of complex hypospadias repair failures

目的探讨不同游离黏膜、带蒂皮瓣或二种组织拼接尿道成形术治疗复杂性尿道下裂修复失败后病例的效果。方法采用3种游离黏膜或带蒂阴茎皮瓣尿道成形治疗尿道下裂修复失败后患者36例，其中带蒂阴茎皮瓣尿道成形7例，舌黏膜与阴茎皮瓣拼接重建尿道3例，结肠黏膜重建尿道2例，1条舌黏膜重建尿道9例，1条颊黏膜重建尿道7例，采用2条口腔内黏膜拼接重建尿道8例。阴茎用弹力绷带包扎4d，每天用抗生素液冲洗尿道1次。结果36例术后随访3～84个月，平均32．6个月。术后2～3周发生尿瘘4例。术后2～3个月新尿道发生狭窄3例，其中吻合口狭窄1例，经尿道扩张5次后排尿通畅；尿道外口狭窄2例，经手术矫正后均排尿通畅，Qmax分别为37．3和28．7ml／s。余者排尿通畅，尿线粗，Qmax 18．0～46．0ml／s，平均26．8ml／s。结论舌黏膜与颊黏膜具有取材方便、创伤小的特点，较适合于尿道下裂修复失败后皮源少患者的尿道重建。

Objective To investigate the result of applying free mucosa grafts or foreskin flaps to treat repair failed hypospadias. Methods Thirty-six patients with repair failed complex hypospadias were treated by foreskin flaps or free mucosal grafts urethroplasty. Of the 36 patients, foreskin flap urethroplasties were performed in 7 patients, buccal mucosal graft urethroplasties in 7, lingual mucosal graft （LMG） urethroplasty in 9, colonic mucosal graft urethroplasty in 2 cases, combined LMG and foreskin flap urethroplasties in 3 patients, two oral mueosal grafts urethroplasties in 8 pa tients. The penis was wrapped with soft, elastic, and roller bandage incorporating the traction suture into the dressing for four days and antibiotic liquid was injected into urethra every day. Results Patients were followed up for 3--84 months（mean 32.6 months）postoperatively. Urethrocutaneous fistulas developed in 4 patients between 2 and 3 weeks postoperatively and urethral strictures developed in 3 patients at 2--4 months postoperatively. Of the 3 patients, anastomotic stenosis developed in 1 patient who underwent 5 urethral dilations and the patient could void well after that. Meatal stenosis developed in 2 patients who needed re-operation and the patients could void well with a peak urinary flow rates of 37.3 and 28.7 ml/s respectively after the re operation. The other patients voided well and the peak urinary flow rates ranged from 18.0 46.0 ml/s. Conclusions The treatment of repair failed hypospadias is a tough problem in urological surgery. Lingual mucosa and buccal mucosa onlay grafts substitution urethroplasty has advantages of easy to harvest, a little trauma to patient and is a good urethral substitution technique for less skin available in patients of repair failed hypospadias.