尿道端端吻合术后狭窄复发的危险因素分析

Analysis of risk factors for recurrent urethral stricture after excision and primary anastomotic urethroplasty

目的分析尿道狭窄患者行尿道端端吻合术(excision and primary anastomotic urethroplasty,EPA)后狭窄复发的危险因素。方法回顾性分析2017年1月至2018年12月上海交通大学附属第六人民医院收治的209例尿道狭窄患者的临床资料。年龄42.1(5~78)岁。肥胖(体质指数>28 kg/m2)25例(12.0%)。既往有糖尿病史12例(5.7%),术前3个月吸烟史103例(49.3%)。术前未行尿道扩张127例(60.8%),尿道扩张1~2次42例(20.1%),尿道扩张≥3次40例(19.1%)。术前有尿道内切开术史56例(26.8%)。术前无尿道成形术史157例(75.1%),尿道成形术1次38例(18.2%),尿道成形术≥2次14例(6.7%)。术前行膀胱造瘘201例(96.2%),未行膀胱造瘘8例(3.8%)。后尿道狭窄183例,球部尿道狭窄26例。狭窄时间35.1(1~360)个月。狭窄段长度(3.19±0.65)cm。病因为外伤190例,医源性损伤12例,炎性狭窄2例,其他5例。患者均行EPA治疗,69例(33.0%)术中行耻骨下缘切除。术后复发标准:拔除导尿管后出现排尿困难,经尿道镜或尿道造影检查提示手术部位尿道狭窄。对可能导致狭窄复发的因素采用Cox比例风险回归模型进行单因素和多因素分析。结果本组209例术后随访18.8(3~32)个月。31例(14.8%)出现狭窄复发,复发时间(5.3±5.6)个月。单因素分析结果显示,狭窄时间(HR=1.007,P<0.001),狭窄段长度(HR=5.334,P<0.001),尿道内切开术史(HR=2.901,P=0.003),尿道扩张≥3次(HR=6.214,P<0.001),尿道成形术1次、≥2次(HR=4.175,P=0.001、HR=9.885,P<0.001),术前3个月吸烟史(HR=2.605,P=0.016),膀胱造瘘(HR=0.231,P=0.006),耻骨下缘切除(HR=6.603,P<0.001)与狭窄复发有相关性。多因素分析结果显示狭窄段长度(HR=4.911,P<0.001),尿道成形术1次、≥2次(HR=2.387,P=0.045、HR=3.688,P=0.015),术前3个月吸烟史(HR=2.730,P=0.030)是狭窄复发的独立危险因素。结论EPA术后尿道狭窄复发多集中在术后6个月内,患者尿道狭段窄长度、尿道成形术史、术前3个月吸烟史是狭窄复发的独立危险因素。

Objective To analysis the risk factors for stricture recurrence after excision and primary anastomotic urethroplasty(EPA).Methods 209 urethral stricture cases managed with EPA were retrospectively studied from January 2017 to December 2018 in our center.Of all the patients,183 cases were diagnosed as posterior urethral stricture and 26 cases were diagnosed as bulbar urethral stricture.Their age ranged from 5 to 78 years(mean 42.1 years).25 cases(12.0%)were defined as the obesity,whose BMI was more than 28 kg/m2.12 cases(5.7%)has the history of diabetes mellitus.103 cases(49.3%)smoked at least three months before operation.127 cases(60.8%)didn't have the history of dilation.42 cases(20.1%)had the history of dilation once or twice.40 cases(19.1%)had the history of dilation more than three times.The history of urethroplasty included once in 38 cases(18.2%)and more than twice in 8 cases(3.8%).The location of stricture included posterior urethral stricture in 183 cases and bulbar stricture in 26 cases.The history of stricture ranged from 1 to 360 months(mean 35.1 months).The stricture length was(3.19±0.65)cm.The causes including trauma in 190 cases,iatrogenic urethral injury in 12 cases,inflammatory in 2 cases and others in 5 cases.The standard of stricture recurrence were defined as the urination difficulty after removal of catheter and endoscopic or radiographic evidence of obstruction in the area of repair.Univariate and multivariate analysis were performed by the use of Cox′s proportional hazards regression model to identify the related factors for stricture recurrence.Result The following up period was ranged from 3 to 32 months(average 18.78 months).Recurrence occurred in 31 cases in the period of 1.0 to 18.0 months(average 5.34 months).Factors had statistical differences in univariate analysis including stricture period(HR=1.007,P<0.001),stricture length(HR=5.334,P<0.001),history of direct vision internal urethrotomy(DVIU)(HR=2.901,P=0.003),history of urethral dilation≥3 times(HR=6.214,P<0.001),history of urethroplasty 1 time,≥2 times(HR=4.175,P=0.001,HR=9.885,P<0.001),3 months smoking before surgery(HR=2.605,P=0.016),suprapubic cystostomy(HR=0.231,P=0.006),inferior pubectomy(HR=6.603,P<0.001).In multivariate analysis stricture length(HR=4.911,P<0.001),history of urethroplasty 1 time,≥2 times(HR=2.387,P=0.045,HR=3.688,P=0.015),3 months smoking before surgery(HR=2.730,P=0.030)were independent risk factors.Conclusion The urethral stricture recurrence mainly occurred within 6 months after surgery.The length of stricture,history of urethroplasty and 3 months smoking before surgery were the independent risk factors for stricture recurrence.