尿道板联合一侧新月形皮瓣治疗小儿尿道下裂的疗效分析

Treatment of hypospadias in children with urethral plate combined with one crescent flap

目的 探讨尿道板联合一侧新月形皮瓣治疗小儿尿道下裂的临床疗效。 方法 回顾性分析我院2017年3月至2018年3月收治的14例尿道下裂患儿的临床资料。年龄(3.3±2.1)岁(1~9岁)。尿道外口均位于阴茎腹侧中远端,伴阴茎轻、中度弯曲,包皮呈帽状堆积于阴茎背侧,腹侧皮肤缺乏,无阴茎、阴囊转位或隐睾等疾病。所有患儿均为首次手术,行尿道板联合一侧新月形皮瓣尿道成形术。术中游离尿道板一侧新月形包皮浅筋膜组织,联合尿道板作为新尿道材料,并使尿道偏离中线缝合。修剪尿道前端开口呈浅"V"形后成形尿道外口,使用背侧肉膜血管蒂加盖新尿道,缝合关闭阴茎头翼瓣成形阴茎头,裁剪包皮覆盖缝合阴茎体。术中留取背侧包皮内板、外板筋膜组织,腹侧包皮内板、外板筋膜组织,行HE染色,比较各组筋膜血管数量,并对浅、深筋膜血管数量进行比较;同时留取腹侧内、外板与尿道板交界处筋膜组织,观察切面组织形态和血管走行情况。 结果 14例手术均顺利完成,术中阴茎伸直前测量阴茎长度为(3.5±0.5)cm(2.7~4.0 cm);冠状沟处阴茎直径(1.2±0.3)cm (1.0~1.8 cm);两翼处阴茎头直径(1.5±0.3)cm (1.2~2.3 cm);尿道板宽度(0.6±0.1)cm (0.4~0.8cm)。完全矫正阴茎弯曲畸形后测量阴茎长度为(3.5±0.5)cm (3.0~4.5 cm);尿道缺损(1.7±0.7)cm (0.8~2.5 cm);按Barcat法分型,其中冠状沟型2例,阴茎前段型7例,阴茎中段型5例。术中留取标本HE染色结果显示,背侧包皮内板筋膜组织的血管数量为(8.5±2.1)支,背侧包皮外板(5.1±1.6)支,腹侧包皮内板(7.6±1.8)支,腹侧包皮外板(4.8±1.6)支,背侧包皮内板筋膜组织血管数量最丰富,多于背侧包皮外板(P=0.033)和腹侧包皮外板(P=0.047),但与腹侧包皮内板比较差异无统计学意义 (P=0.326);背侧与腹侧包皮外板筋膜组织血管数量的差异无统计学意义(P=0.682)。靠近皮肤的浅筋膜组织血管数量为(10.3±1.4)支,显著高于深筋膜组织[(4.2±1.7)支,P=0.037]。腹侧内、外板与尿道板交界处横切面可见浅筋膜有较多的血管分支向尿道板方向走行。14例均获得随访,随访时间(5.4±2.1)个月(3~9个月)。所有患儿阴茎伸直满意,尿道口无裂开,无排尿费力,排尿无分叉,无尿瘘。1例阴茎中段型患儿发生术后感染,予抗感染治疗后治愈。1例阴茎前段型患儿术后尿线偏细,但无排尿困难,予F6金属尿道扩张器扩张2个月后,尿线增粗。 结论 尿道板联合一侧新月形皮瓣尿道成形术治疗尿道下裂的术后并发症少,外观满意。对于术中无需横断尿道板即可满意伸直阴茎的患儿,尤其是对阴茎发育较差、制作新尿道材料不充足的的患儿,提供了一种可选的手术方式。尿道板两侧的包皮浅筋膜组织血供丰富,是新尿道的理想材料。

Objective To investigate the clinical effect of urethral plate combined with unilateral crescent flap in the treatment of hypospadias in children.Methods The clinical data of 14 cases of hypospadias treated from March 2017 to March 2018 were retrospectively analyzed, with average age of (3.3±2.1) years.The external urethral orifice was located in the middle and distal part of the ventral side of the penis, with mild and moderate bends of the penis.The prepuce was piling up on the penile dorsal side, the ventral skin was deficient, and there was no concomitant disease such as penis scrotum transposition or cryptorchidism.All children were primarily treated with urethroplasty with urethral plate and one crescent flap.One side of the free urethral plate had a crescent superficial fascia, which was used as the new urethral material together with the urethral plate. By design, the urethra sutured deviating from the midline.The external urethral orifice was formed by trimming the anterior opening of urethra in the form of shallow "V" shape, and the new urethra was covered with the dorsal fleshy vascular pedicle. The pterygoid flap of the penis was sutured to form the penile head, and the foreskin was cut to cover the body of the penis.The specimens were taken for HE staining.Results The operation was successfully completed in 14 children.The length of the penis was measured before it is stretched out.The penile length was(3.5±0.5)cm, the penile diameter was(1.2±0.3) cm at the coronal sulcus, and the diameter of the tortoise head was(1.5±0.3)cm at the pterygoid.The width of urethral plate was(0.6±0.1)cm.Remeasurement was performed after complete correction of penile bending deformity.The length of the penis was(3.5±0.5)cm, and the urethral defect was(1.7±0.7)cm.According to Barcat method, there were 2 cases of coronal sulcus type, 7 cases of anterior penile type and 5 cases of middle penile type. The results of HE staining showed that the number of blood vessels in the dorsal prepuce and fascia was(8.5±2.1), dorsal foreskin plate was (5.1±1.6), ventral prepuce internal plates was(7.6±1.8), and ventral outer prepuce plates was(4.8±1.6). The number of superficial fascia vessels and deep fascia vessels were(10.3±1.4)and (4.2±1.7). The analysis of variance showed that there was significant difference in the mean number among groups(P=0.036), which was compared with each other by SNK-q test.The number of fasciae in dorsal prepuce was the most abundant, there was significant difference between dorsal and outer prepuce(P=0.033), and there was also significant difference with ventral prepuce(P=0.047). But there was no significant difference between the two groups(P=0.326). There was no significant difference in the number of blood vessels between the dorsal and ventral prepuce(P=0.682). The number of superficial fascia vessels near the skin was significantly more than that of deep fascia(P=0.037). On the transverse plane, there are more branches of the superficial fascia to the urethral plate at the junction of the ventral external plate and the urethral plate.All 14 cases were followed up for 3 to 9 months with an average of(5.4±2.1)months.The penis was straight and satisfactory, urethral orifice was not cracked, urination was laborious and not forked, and there was no fistula.One patient with middle penile type developed postoperative infection and was controlled after anti-infective treatment.One patient with anterior penile type had slight urination after operation, but had no difficulty in urination. F6 metal urethral dilator was used to dilate for 2 months, and the urination was normal. Conclusion Urethral plate combined with crescent flap urethroplasty for hypospadias has a satisfactory appearance and fewer complications.It provides an optional operative method for the children who need no transection of urethra plate to straighten the penis, especially for the poor development of the penis and the insufficiency of the new urethral materials.The superficial fascia tissue on both sides of the urethral plate is an ideal material for the new urethra because of its abundant blood supply adjacent to the urethral plate and direct vascular connection.