泌尿外科在多学科联合诊治泄殖腔畸形中的作用

Value of urologists in multidisciplinary treatment of cloacal malformations

目的探讨在泄殖腔畸形多学科联合诊治（multidisciplinary treatment，MDT）中泌尿外科的作用。方法回顾性分析我院2010年10月至2016年6月收治的泄殖腔畸形患儿资料。在泄殖腔畸形根治术前，泌尿外科行膀胱镜检查了解共同通道、尿道、阴道和直肠瘘管的位置及前三者的长度，同时行逆行造影明确各通道和膀胱、直肠的情况。根据检查结果MDT小组讨论制定手术方案。术中泌尿外科负责泌尿生殖窦游离、尿道和阴道重建、外阴重建和部分会阴体重建。术后泌尿外科进行外阴部外观、排尿及泌尿系统功能随访。结果总计12例患儿接受治疗。11例接受泌尿生殖窦整体游离拖出成形术，另1例因共同通道长、尿道短而接受共同通道尿道成形＋经腹右侧阴道翻转阴道成形术。术后平均随访时间28.4个月，所有患儿肾功能均保持稳定，控尿Ⅰ级7例，Ⅱ级5例。排尿后残余尿〉30 ml者1例，目前随访中；尿道外口狭窄1例，扩张3次后恢复；1例出现尿道阴道瘘，尚未处理。结论泄殖腔畸形MDT可以充分发挥泌尿外科专科特长。术前完整了解患儿的病变，尤其是尿道、阴道、膀胱和直肠、共同通道的解剖特点，以及他们相互间的关系，明确治疗方案；术中负责游离共同通道、尿道与阴道等泌尿生殖窦结构，使尿道开口和阴道开口能够尽可能无张力下降到会阴部；术后泌尿外科和普外科一起进行随访。如此能对泄殖腔畸形患儿的预后有显著帮助。

Objective To evaluate the value of urologists in multidisciplinary treatment （MDT） of cloacal malformation. Methods The clinical data were reviewed for all cloacal malformation cases from October 2010 to June 2016. The urologists assessed the positions of common channel, urethra, vagina and rectal fistula by cystoscope before radical treatment and the length of the first three as well. Retrograde urography was performed after endoscopy to comprehend the status of urogenital sinus and rectum. A MDT team formulated the plan according to the above results. Surgical mobilization was performed for urogenital sinus and the reconstruction of urethra, vagina, vuvla and perineum. The follow-up of cosmetic of vulva and the functions of voiding and kidney were also followed up. Results Among them, 11 cases underwent total urogenital sinus mobilization. And another case had urethral mobilization and right vagina was switched to left distal vagina due to a long common channel and a short urethra During a mean follow-up period of 28.4 months, all patients could achieve stable renal function. The grades of urinary continence were I （n = 7） and II （n = 5）. One case had residual urine ~30 ml. Another case of urethral meatus stenosis was relieved after dilation for 3 times. And one case of urethra-vagina fistula was still tracked. Conclusions MDT mode of urologists is ideal for cloacal malformation. Better preoperative assessments may be made. During surgery, urologists are capable of mobilizing urogenital sinus and reconstructing urethra, vagina, vuvla and perineum- And, along with general surgeons, they can also contribute to postoperative functional follow-ups of urinarysystem. Thus a better patient prognosis is obtained.