发育不良的尿道海绵体成形阴茎头在降低近端型尿道下裂术后阴茎头并发症中的应用

Reducing the complications on glan of proximal hypospadias repair by using dysplasia corpora spongiosum glanuloplasty

目的探讨采用发育不良的尿道海绵体成形阴茎头以降低近端型尿道下裂术后阴茎头裂开和冠状沟部尿道瘘发生、改善阴茎头外观的治疗效果。方法回顾性分析2014年1月至2016年12月行Duckett或背侧包皮岛状皮瓣尿道板重建卷管成形术的75例近端型尿道下裂患儿的临床资料。其中,采用尿道海绵体阴茎头成形的作为研究组(47例),采用常规阴茎头成形的作为对照组(28例)。研究组和对照组患儿的手术年龄分别为(32.65±15.75)个月和(32.05±17.26)个月。研究组将尿道板两侧发育不良的尿道海绵体与其近端正常海绵体分离,联合其外侧宽0.3~0.4 cm的Buck's筋膜一起在阴茎海绵体白膜的表面游离至阴茎头,参与形成阴茎头两侧翼,并覆盖于新成形尿道表面共同成形阴茎头。对照组不分离发育不良的尿道海绵体组织及Buck's筋膜,冠状沟段尿道仅有皮下浅筋膜及皮肤覆盖。比较两组阴茎头外形和并发症发生情况。结果研究组重建尿道长度为(3.95±1.04)cm,尿道海绵体分叉点到冠状沟距离为(2.39±0.85)cm,尿道板两侧发育不良海绵体宽度为(0.37±0.18)cm;两侧海绵体及Buck's筋膜合拢后的长度为(1.74±0.36)cm,宽度为(0.87±0.29)cm;术前冠状沟前后径为(0.79±0.12)cm,术后为(0.83±0.07)cm,手术前、后比较,差异无统计学意义(P=0.093)。对照组重建尿道长度为(4.11±1.26)cm;术前冠状沟前后径为(0.82±0.07)cm,术后为(0.84±0.23)cm,手术前、后比较,差异无统计学意义(P=0.110)。研究组和对照组冠状沟前后径的术后增加差值对比,差异有统计学意义(P=0.047)。所有75例患儿术后均予一年以上随访,随访时间(20.36±6.29)个月。研究组出现尿瘘10例(21.28%),其中冠状沟瘘2例(4.26%)、阴茎体部瘘4例(8.51%)、阴茎根部瘘4例(8.51%),未出现阴茎头裂开现象;出现尿道狭窄2例(4.26%),均位于阴茎根部;出现尿道憩室4例(8.51%)。对照组出现尿瘘15例(53.57%),其中冠状沟瘘8例(28.57%)、阴茎体部瘘3例(10.71%)、阴茎根部瘘4例(14.29%),有2例(7.14%)出现阴茎头裂开现象;出现尿道狭窄4例(14.29%),2例位于阴茎根部,2例位于冠状沟水平;出现尿道憩室1例(3.57%);阴茎弯曲复发1例(3.57%)。研究组冠状沟瘘、阴茎头裂开及尿道狭窄发生率均明显低于对照组,组间比较,差异均有统计学意义(P<0.001、P=0.033和P=0.008);而研究组尿道憩室发生率高于对照组,组间比较,差异亦有统计学意义(P=0.040)。结论采用发育不良的尿道海绵体成形阴茎头增加了阴茎头的组织量,有效地减少了冠状沟尿道瘘和阴茎头裂开的发生,改善了阴茎头外形,但有尿道憩室发生率上升的情况。

Objective To reduce the occurrence of glanular dehiscence and coronal fistula and to improve the glanular appearance of proximal hypospadias through a new method of utilizing dysplasic corpora spongiosum for forming glans.Methods A prospective comparative study was conducted over a period of 2 years from January 2014 to December 2016.A total of 75 children with primary hypospadias undergoing Duckett or Onlay procedure were assigned into experimental group(n=47)and control group(n=28).The mean operative age was(32.65±15.75)vs.(32.05±17.2)months in experimental and control groups.In experimental group,dysplasic corpora spongiosum separating dysplasia corpora spongiosum from its proximal normal corpora spongiosum was combined with Buck's fascia 0.3-0.4 cm wide for glanular wing on the surface of corpus cavernosum for covering coronary urethra and forming glans.In control group,only subcutaneous superficial fascia and skin were utilized for covering coronary urethra.Glanular appearance and complications were compared.Results In experimental group,the mean length of reconstructed urethra was(3.95±1.04)cm,the mean distance from the bifurcation point of urethra sponge to coronal sulcus(2.39±0.85)cm,the mean width of dysplasic corpora spongiosum on both sides of urethral plate(0.37±0.18)cm,the mean length and width of dysplasic corpora spongiosum plus Buck's fascia(1.74±0.36)and(0.87±0.29)cm and the mean pre/post-operative coronal anteroposterior diameter(0.79±0.12)and(0.83±0.07)cm.No statistical difference existed between pre-and post-operation(P=0.093).In control group,the mean length of reconstructed urethra was(4.11±1.26)cm and the mean pre and post-operative coronal anteroposterior diameter(0.82±0.07)and(0.84±0.23)cm.No statistical difference existed between pre-and post-operation(P=0.110).However,the inter-group difference of pre-and post-operation in coronal anteroposterior diameters was statistically significant(P=0.047).The mean postoperative follow-up period was(20.36±6.29)months.In experimental group,there were urinary fistula(n=10,21.28%),including coronary fistula(n=2,4.26%),mid penis(n=4,8.51%)and proximal penis(n=4,8.51%).There was no glanular dehiscence.Urethral stricture was located in proximal penis(n=2,4.26%)and urethral diverticulum(n=4,8.51%).In control group,there were urinary fistula(n=15,53.57%),coronary fistula(n=8,28.57%),mid penis(n=3,10.71%),proximal penis(n=4,14.29%),glanular dehiscence(n=2,7.14%);4 cases(14.29%)with urethral stricture,the location was proximal penis(n=2)and level of coronary groove(n=2);urethral diverticulum(n=1,3.57%)and recurrent penile curvature(n=1,3.57%).The incidence of coronary fistula(P<0.001),glanular dehiscence(P=0.033)and urethral stricture(P=0.008)were significantly lower in experimental group than those in control group.However,the incidence of urethral diverticulum was higher than that of control group(P=0.040).Conclusions Dysplasic corpora spongiosum has been utilized for augmenting the amount of glanular tissue.Such a procedure effectively reduces the occurrence of coronary urethral fistula and glanular dehiscence and improves the appearance of glans.However,there is an elevated incidence of urethral diverticulum.