游离尿道板卷管尿道成形术一期矫治婴幼儿阴茎体型尿道上裂的疗效分析

Analysis of the effect about tubularized urethral plate disassembly for one-stage midshaft epispadias repair in infant

目的探讨游离尿道板卷管尿道成形术治疗婴幼儿单纯阴茎体型尿道上裂的疗效。方法回顾性分析2016年1月至2018年9月广州市妇女儿童医疗中心收治的10例阴茎体型尿道上裂患儿的病例资料。年龄18~36个月,平均27.5个月。主诉均为发现尿道口开口于阴茎背侧。查体:阴茎短小,阴茎头扁平,宽度17~25 mm,平均20.7 mm;阴茎背曲15°~30°,平均21.5°。术前膀胱造影检查提示其中3例合并单侧膀胱输尿管反流(Ⅰ级),所有病例尿常规检查白细胞均阴性。全麻,患儿取仰卧位。术中于尿道板与海绵体背侧白膜之间的间隙游离,以减少出血并保证游离尿道板血供。距阴茎头1.5 cm处绕冠状沟做环形切口达阴茎海绵体白膜,阴茎皮肤沿白膜脱套至阴茎根部。游离尿道板及脱套纠正阴茎背曲,注意此类患儿海绵体背侧的神经血管束会远离正常位置而转向外下方,应避免损伤,以保护阴茎头血供。2例因背曲矫正不满意,行阴茎腹侧白膜折叠。将游离尿道板卷管,以F6~8双腔导尿管为支架,6-0可吸收线连续内翻缝合尿道板形成新尿道。将两侧海绵体在根部纵行分离,将新尿道完全移位至海绵体腹侧并在阴茎头腹侧成形为裂隙状尿道口。术后留置双腔尿管10~14 d,静脉应用抗生素5 d至拆除阴茎敷料,改口服抗生素至拔除导尿管。结果本组10例手术均顺利完成。手术时间130~200 min,平均157 min。术中出血量5~30 ml,平均16 ml。1例术后第1天出现阴茎头皮肤发黑,考虑与术中游离阴茎头两翼过深、阴茎脱套过程中损伤背侧神经血管束分支有关,予加强换药,1个月后局部出现萎缩、瘢痕形成,无皮肤切口感染病例。10例术后随访3~40个月,平均21个月。2例拔除导尿管后发现阴茎腹侧近冠状沟处尿道瘘,术后6个月再次手术修补瘘口治愈。8例阴茎背曲完全矫正,2例残留背曲10°~15°,予观察。3例术前膀胱造影提示单侧膀胱输尿管反流者,术后6~12个月复查仍存在膀胱输尿管反流,因尿常规检查白细胞阴性,未予治疗,继续观察。所有患儿排尿通畅,术后尿流率5~9 ml/s,平均6.7 ml/s。结论游离尿道板卷管尿道成形术治疗单纯阴茎体型尿道上裂方法简单,可有效矫治阴茎体背曲。

Objective To evaluate the safety and efficacy of tabularized urethral plate disassembly for epispadias repair in infant.Methods From January 2016 to September 2018,10 boys aged between 18 to 36 months old with mishaft epispadias were included.The main complaint was that the urethral opening was found on the dorsal side of the penis.Preoperative cystography revealed that 3 of them had unilateral vesicoureteral reflux(GradeⅠ),and white blood cells in routine urinary in all 10 patients were negative.Physical examination:the penis is short and flat,the width is 17-25 mm,average is 20.7 mm,the penis curvature is 15°-30°,average is 21.5°,and the urethral opening located on the dorsal side of the penis.The anesthesia method was selected for tracheal intubation,intravenous anesthesia combined with caudal anesthesia,and the surgical position was supine position.The surgical method:one stage of tabularized urethral plate disassembly urethroplasty:during the operation,the penile curve was corrected by free urethral plate and penile degloving.Two of them were unsatisfied with the correction of the curvature,and the ventral tunica folded was applicate.To avoid urethral plate ischemia,attention should pay to blood supply protection.The two corpus cavernosum are separated in the root,and the urethra is completely displaced to the ventral side of the cavernous body.The ventral side of the urethral under glans is shaped into a fissured that conforms to the anatomy.The prognosis and surgical choice of the midshaft epispadias were discussed combined with literature.Result The operation time was 130-200 min with an average of 157 mins.Intraoperative hemorrhage 5-30 ml,average is 16 ml,1 case of glans skin was black one day after surgery,with enhanced dressing change.After 1 month,the glans was local atrophy and scar formation.No skin incision infection case.After discharge from the hospital,the follow up through the internet and outpatients for 3-40 months,average is 21 months,2 cases with urethral fistula,more surgery to repair the fistula successfully after 6 months.The penile curvature was corrected in 8 cases,and the residual curvature of 2 cases was about 10-15°,which was temporarily observed.Patients with unilateral vesicoureteral reflux preoperatively,they still suffered from vesicoureteral reflux in the 6-12 months regular review after surgery without any intervention due to white blood cell was negative in urine routine.All cases had urinary patency and no cases with urethral stricture.Conclusion Tubularized urethral plate disassembly is a effective and simple procedure that can correct the midshaft epispadias in infant.