儿童复杂近端型尿道下裂术后尿道狭窄的病理改变及治疗

Pathologic characteristics of urethral stricture after correction of complex proximal hypospadias in children and its treatment

目的探讨儿童复杂近端型尿道下裂术后尿道狭窄的病理改变及治疗。方法对2008年10月-2017年6月就诊于我院小儿外科的8例尿道下裂术后尿道狭窄病例进行回顾性分析。结果 8例患儿初次就诊于我院时年龄为2~11岁,平均4.85岁,初均接受皮瓣卷管尿道成形术。初次手术前阴茎型尿道下裂4例,阴茎阴囊型尿道下裂1例,会阴型尿道下裂3例。8例复杂近端型尿道下裂术后尿道狭窄的病理分型为Ⅰ型(尿道外口狭窄继发尿瘘)、Ⅱ型(尿道节段性狭窄)、Ⅲ型(尿道外口狭窄、尿瘘及憩室共存)、Ⅳ型(尿道外口狭窄、尿道狭窄、继发尿瘘及尿道扩张),各占2例。Ⅰ型尿道狭窄通过尿道外口扩张,Mathieu阴茎头尿道成形术治愈;Ⅱ型尿道狭窄通过海绵体尿道端端吻合术或狭窄段纵形切开尿管置入支撑治疗治愈;Ⅲ型尿道狭窄通过分期手术治疗,即一期完成憩室消除、阴茎头尿道板成形、尿瘘修补术,二期完成阴茎头尿道成形术;Ⅳ型尿道狭窄通过分期手术治疗,即一期实施瘢痕处尿道造口,远端尿道尿管支撑治疗,待瘢痕软化后二期实施尿道造口皮瓣覆盖修补及阴茎头尿道成形术。6例治愈者自初次手术至治愈的时间为14~62个月,平均为30.17个月;接受治疗的次数为2~9次,平均为5次。结论儿童尿道下裂术后尿道狭窄多发生于复杂近端型尿道下裂、初次手术采用皮瓣卷管尿道成形术者。消除狭窄环或狭窄节段后,以阴茎腹侧或背侧血运较好、具有一定延展性的皮瓣修补尿道是合适的处理方式。

Objective To study the pathologic characteristics of urethral stricture after correction of complex proximal hypospadias in children and its treatment. Methods Clinical data about 8 children who admitted to our department for their urethral stricture after operations of complex proximal hypospadias from October 2008 to June 2017 were analyzed retrospectively. Results The age of 8 children at first admission ranged from 2 years to 11 years, with a mean age of 4.85 years. All of them received flap tube urethroplasty as their primary procedures. Before primary operations, there were 4 cases with penile type hyposadias, one case with penoscrotal type and 3 cases with perineal type. The pathology of urethral stricture were classified as： typeⅠ（2 cases）： meatal stricture followed by fistula, typeⅡ（2 cases）： segmental stricture of urethra, typeⅢ（2 cases）： coexistence of meatal stricture, fistula and diverticulum, and typeⅣ（2 cases）： meatal stricture and urethral stricture followed by fistula and urethral dilatation. Patients with typeⅠstricture were cured by meatal dilation or Mathieu procedure of glan urethroplasty. Cases with typeⅡstricture were cured by end to end spongiosum urethral anastomosis or incision of the stricture and insertion of urethral tube. Cases with type Ⅲstricture received two-stage repair, with primarily diverticulum excision, glan urethral plate palsty and fistula repair, and glan urethral plasty secondarily. Cases with type Ⅳ stricture also received two-stage repair, with primarily scared urethral ostomy and urethral tube insertion of the distal urethral for dilation, and secondary flap repair for the ostomy and glan urethral plasty after scar softened completely. Length of treatment for 6 cured patients ranged from 14 months to 62 months with a mean value of 30.17 months. Frequency for treatment ranged from 2 to 9 times with a mean value of 5 times. Conclusion Postoperative urethral stricture most commonly occurrs in children suffered from complex proximal hypospadias who have received flap tube as their primary urethroplasty. Longitudinal incision of the stricture loop or segmental stricture, followed by urethroplasty using ventral or dorsal penile skin flap with relatively good blood supply and flexibility to replace the unhealthy urethral are the appropriate option for cure.