包皮完整的尿道上裂的诊断和治疗

Diagnosis and treatment of epispadias with complete prepuce

目的探讨包皮完整的尿道上裂的诊断和治疗经验。方法回顾性分析2007年1月至2017年4月我院收治的5例包皮完整的尿道上裂患儿的临床资料。患儿就诊年龄34～66个月，平均44.3个月。主诉均为阴茎短小，包皮不能完全上翻显露阴茎头。其中2例术前有尿失禁。查体：阴茎短小，外观成鸟嘴状，包皮完整，包皮口狭小不能上翻外露阴茎头，触诊阴茎海绵体背侧间距宽，且上翘，阴茎头扁平宽大，上翻包皮后可见尿道外口位于阴茎背侧。5例中术前考虑尿道上裂3例；另2例曾诊为隐匿阴茎，行包皮成形术时暴露阴茎头后发现尿道上裂而确诊。尿道上裂分型：冠状沟型2例，阴茎体型3例。5例均行Thiersch-Duplay尿道成形术。结合文献，对包皮完整的尿道上裂的发病情况、发病机制、临床表现、诊治以及预后进行分析。结果术后随访3～98个月，平均44.5个月。1例术后1个月出现尿线细、排尿费力合并尿道狭窄，予尿道扩张、留置尿管1个月后治愈；3例对阴茎长度不满意，其中1例术后8年由于腹侧包皮赘积，要求行包皮成形术。术后除1例仍有尿失禁外，其余4例均可正常控制排尿。2例术前有尿失禁的患儿术后行尿动力学检查未见异常，行排尿性膀胱尿道造影示1例有右侧Ⅱ度膀胱输尿管反流，1例未见反流。结论包皮完整的尿道上裂临床罕见，术前明确诊断困难，需结合患儿病史、体格检查以及必要的辅助检查进行综合诊断。包皮完整的尿道上裂手术并发症和术后尿失禁相对较少，阴茎长度是影响手术满意度的重要因素。

ObjectiveTo summarize the diagnosis and treatment of epispadias with complete prepuce.MethodsBetween January 2007 and April 2017, clinical records were reviewed for 5 patients diagnosed as epispadias with complete prepuce. The patients were 34 to 66 months old （mean age 44.3 months） , who presented with short beaked penis and nonretractile prepuce. A dorsal midline gap between corpora cavernosa could be felt on palpation. There was dorsal chordee with broad spade like glans. The preputial opening was stenosed and dorsally placed urethral opening after retraction of the prepuce. Two patients were incontinent before surgery. Epispadias were coronal type in 2 cases and penile type in 3 cases. All 5 cases were repaired by Thiersch-Duplay procedure.ResultsThe mean follow-up time was 44.5 months （ranged 3 to 98 months）. The stricture occurred in 1 patient 1 month after operation, and after dilation and indwelling catheter for a month, the problem resolved. One needed a secondary preputial plasty due to redundant ventral foreskin 8 years after operation. In 3 of 5 cases, parental satisfaction was not achieved mainly due to short length. Only 1 case was incontinent after surgery and the other four achieved urinary continence. Voiding cystourethrogram （VCUG） and ultrasonography （USG） were done in 2 patients who were incontinent before surgery. One case presented right vesicoureteral reflux of Grade Ⅱ and the other was normal. The urodynamic results of 2 patients were normal.ConclusionsEpispadias with complete prepuce is extremely rare and its preoperative diagnosis remains difficult. A definitive diagnosis is based upon history, physical examination and imaging tests. Fewer complications and better continence rates were achieved in the boys with epispadias and intact prepuce. Penile length is an important factor affecting surgical outcome.