带蒂睾丸鞘膜瓣覆盖新尿道在尿道下裂再次手术中的应用

The application of pedicled tunica vaginalis flap cover new urethra in redo and second-stage hypospadias repair

目的探讨带蒂睾丸鞘膜瓣覆盖新尿道在尿道下裂再次手术中的临床疗效。方法回顾性分析2013年1月至2015年12月我院收治的45例尿道下裂再次手术患儿的临床资料。年龄1岁3个月～9岁4个月，中位年龄5岁3个月。根据患儿病史特点分为尿道下裂术后尿道裂开组（A组）和尿道下裂分期手术中的二期手术组（B组）。A组距前次手术的时间为6～14个月，平均8.3个月；阴茎勃起伸直或有〈30°的轻度弯曲；其中12例为阴茎体部的尿道裂开（A1组），15例阴茎头及远端尿道裂开且尿道开口于阴茎体（A2组）。B组距一期手术的时间为6～8个月，平均6.5个月；现尿道开口于阴茎阴囊交界处。所有患儿在完成新尿道成形术后，游离合适大小的带蒂睾丸鞘膜瓣覆盖新建尿道。结果A组中2例伴有轻度下弯而行保留背侧神经血管束的阴茎海绵体背侧白膜折叠术伸直阴茎；B组勃起试验均提示阴茎无下弯。A1组12例修复尿道长度10～15 mm，平均12 mm；A2组尿道开口于阴茎远端8例，阴茎中部7例，修复尿道长度18～31 mm，平均26 mm；B组尿道均开口于阴茎阴囊交界处，修复尿道长度33～45 mm，平均37 mm。45例患儿术后均未出现阴囊血肿。1例阴囊红肿，经抗感染治疗后好转；2例睾丸位置抬高至阴囊上方，1例阴茎顺时针扭转；所有患者拔管后无排尿困难。拔管后6例即刻出现尿道皮肤瘘，其中A2组4例，B组2例；观察6个月后其中1例尿道皮肤瘘自愈，5例仍存在，予尿道皮肤瘘修补。术后随访1～4年，平均1.8年。随访期间A2组1例再次出现尿道皮肤瘘，B组1例再次出现尿道皮肤瘘且伴有尿道口狭窄，此2例尿道皮肤瘘行修补手术，尿道狭窄给予定期尿道扩张。未出现尿道憩室及阴茎下弯。结论带蒂睾丸鞘膜瓣可作为新尿道的防水组织应用于尿道下裂再次手术，术后尿道皮肤瘘的发生率较低。

ObjectiveTo investigate the application of pedicled tunica vaginalis flap cover new urethra in redo and second-stage hypospadias repair.MethodsRetrospective analysis was performed in 45 redo hypospadias repair cases, aged from 1 year 3 months to 9 years 4 months （median 5 years 3month）. All patients were divided into urethral dehiscence after hypospadias repair （group A） and the second stage surgery of two-stage hypospadias repair （group B） based on medical history. According to the site of dehiscence, the group A were further divided into midshaft urethral dehiscence （A1） and glans and distal urethral dehiscence with urethral opening located on midshaft （A2）. After new urethra was completed, the appropriate size of the pedicledtunica vaginalis flap was transferred to cover the new urethra.ResultsThere was no scrotal hematoma occurred in all 45 cases, and somecomplications occurred, including scrotal swelling in 1 case, high-riding testicle in 2 cases, penile clockwise torsion in 1 case, urethrocutaneous fistula in 6 cases. All the 45 cases were followed up for 1 to 4 years, with mean of 1.8 years. One more urethrocutaneous fistula occurred in group A2 and 1 more urethrocutaneous fistula with urethral stricture occurred in group B. There was no penile curvature and urethral diverticulum occurred in all cases.ConclusionsPedicled tunica vaginalis flap could be used as waterproofing layer to cover new urethra in redo hypospadias repair and presented a low incidence rate of postoperative complications.