镶嵌式包皮内板尿道成形术治疗尿道下裂临床分析

Inlay internal preputial graft urethroplasty for hypospadias repair

目的 尿道板中央切开卷管尿道成形术（tubularized incised plate,TIP,又称Snodgrass术）近20年成为了尿道下裂的主流术式之一,随着其应用范围的扩大该手术的局限性也逐步显现.本文旨在探讨在TIP基础上辅以包皮内板镶嵌的尿道成形术在临床应用价值以拓展TIP手术的适用范围.方法 回顾2009年1月至2013年12月,508例尿道下裂病例,比较198例行单纯TIP（经典TIP组）,150例行口腔黏膜镶嵌式尿道成形术（口腔黏膜镶嵌组）与160例行包皮内板镶嵌式尿道成形术（包皮内板镶嵌组）患儿的治疗效果.患儿年龄6个月～3岁,平均1.2岁；均为初次手术的远端型尿道下裂患儿.在镶嵌病例中,测量切开尿道板间隙的长度及宽度,取下唇口腔黏膜或自体游离全层包皮内板补片填补于尿道板切开间隙,补片宽度在0.5～0.8 cm,长度在0.5～1.5 cm,补片边缘与尿道板内侧切缘缝合,再将镶嵌后的尿道板卷管成形尿道.术后3周拔除尿管自主排尿.统计采用卡方检验,P＜0.05为差异有统计学意义.结果 术后随访6～24个月,平均18个月.结果显示,在经典TIP组尿瘘发生率为3.0％ （6/198）,尿道狭窄发生率为3.0％ （6/198）,总体成功率为93.9％（189/198）；口腔黏膜镶嵌组尿瘘发生率为3.3％（5/150）,尿道狭窄发生率为2.7％（4/150）,总体成功率为94.0％（141/150）；包皮内板镶嵌组尿瘘发生率为3.1％（5/160）,尿道狭窄发生率为4.4％ （7/160）,总体成功率为92.5％（149/160）.比较标准TIP组与包皮内板镶嵌组、口腔黏膜镶嵌组与包皮内板镶嵌组的手术成功率和并发症发生率,结果显示差异没有统计学意义.结论 对于阴茎体发育正常,无明显阴茎弯曲或弯曲程度较轻的患儿,可以通过皮肤脱套/白膜折叠纠正的初治远端型尿道下裂,通过包皮内板镶嵌,避免了获取口腔黏膜的创伤又结合了TIP术式的优点；具有成功率高,整形效果好,手术创伤小的优点.这一改良拓展了保留尿道板手术的临床应用.

Objective Over the past two decades,Snodgrass tubularized incised plate （TIP） urethroplasty has become one of dominant operative techniques because of wide applications and excellent cosmetics.However,it has also many limitations.Our goal was to assess the effectiveness of inlay internal preputial graft for expanding the applications of TIP.Methods Between January 2009 and December 2013,a total of 508 primary distal cases underwent urethroplasty with standard TIP hypospadias repair （n =198）,inlay buccal mucosa graft （n =150） and inlay internal preputial graft （n =160）.The mean age was 1.6 （1-4） years.In inlay graft groups,buccal mucosa or internal preputial graft was inserted between mid-line split urethral plate.The clinical data were analyzed statistically by x2.P〈0.05 was deemed significant.Results The average follow-up period was 18 （6-24） months.The incidence of urinary fistula was 3.0% （6/198） ;meatal stenosis 3.0% （6/198） in standard TIP group; 3.3%（5/150）and 2.7%（4/150）in inlay buccal mucosa graft group; 1.25%（2/160） and 4.4% （7/160）in inlay internal preputial graft group.Overall success rates were 93.9% （189/198）,94.0% （141/150） and 92.5% （149/160） respectively.Compared to STIP group,inlay buccal mucosa graft and inlay internal preputial graft groups,surgery success rate and complication rate showed no statistically significant difference （P〉0.05）.Conclusions For patients with primary distal type of hypospadias,normal penile development and no obvious chordee,corrections may be made by skin degloving or tunica albuginea folding.Dorsal inlay graft urethroplasty is efficacious for hypospadias repair with a high success rate and excellent cosmetic outcomes.Furthermore inner prepuce may be easily obtained without extra damage.