改良Koyanagi尿道成形术的手术细节改进和中远期随访及评价

Efficacy of modified Koyanagi technique for proximal hypospadias and its medium-to-long term follow-ups at a single medical center

目的探讨改良Koyanagi尿道成形术手术细节的再改良以及治疗近段型尿道下裂的中远期疗效。方法收集2012年1月至2021年3月初次行Koyanagi-Huang-Zhang尿道成形术及新改良Koyanagi-Huang-Zhang尿道成形术共133例患儿的临床资料和随访资料,平均手术时年龄3岁7个月,范围为1岁4个月至17岁。按改良Barcat分型,外观表型均为近端型尿道下裂,其中阴茎阴囊交界型26例,阴囊型76例,会阴型31例。手术细节改良点为尿道口成形方式和尿道板重建缝合方式,随访方式为电话询问或门诊面谈及体格检查。中期随访内容包括:并发症发生率、HOSE评分、尿流率以及Koyanagi-Huang-Zhang尿道成形术和新改良Koyanagi-Huang-Zhang尿道成形术组间的比较。远期随访包括:远期排尿情况、阴茎外观情况和性功能情况。结果133例尿道下裂患儿纳入本研究(占同期行尿道成形术2068例的6.4%),中期随访到详细资料的患儿126例,随访率94.7%,失访率5.3%。共有尿瘘5例,尿道裂开20例,尿道口狭窄3例,阴茎残余下弯10例,合并2种及以上畸形患儿8例,分别是尿道裂开+尿瘘1例、尿道裂开+残余下弯6例、尿道裂开+尿瘘+尿道憩室1例。平均尿流率(8.4±2.6)ml/s,最大尿流率(16.6±4.1)ml/s。Koyanagi-Huang-Zhang尿道成形术组的HOSE评分为(14.11±1.44)分,并发症发生率为39.28%(33/84),尿道裂开7例;新改良Koyanagi-Huang-Zhang尿道成形术组HOSE评分为(14.45±1.04)分,并发症发生率为30.95%(13/42),尿道裂开3例。两组间比较,除尿道裂开发生率差异有统计学意义外,其余均无统计学意义。远期随访到详细资料的患儿46例,随访率52.9%,失访率47.1%。随访时间5.92年,平均随访截点年龄9岁(6岁6个月~18岁4个月)。15.22%的患儿存在排尿方面的问题,54.35%的患儿家属对患儿阴茎外观很满意,45.65%较满意,所有患儿均不存在阴茎勃起功能障碍、勃起疼痛等情况。结论Koyanagi-Huang-Zhang尿道成形术及其改良术式对于近段型尿道下裂Ⅰ期修复疗效确切,其手术方法易于学习掌握,有较好的中远期疗效,但需注意尿道裂开的预防。

Objective To explore the modified Koyanagi technique and its medium-to-long-term outcomes for proximal hypospadias.Methods From January 2012 to March 2021,retrospective review was conducted for clinical data of 133 children undergoing Koyanagi-Huang-Zhang urethroplasty or modified Koyanagi-Huang-Zhang urethroplasty for proximal hypospadias.The major criteria of improvement are new approaches of glansplasty and urethral plate suturing.Telephone inquires and outpatient physical examinations were performed during follow-ups.The medium-term follow-ups included incidence of urethral complications,hypospadias objective scoring evaluation(HOSE)score,urinary flow rate and comparisons between Koyanagi-Huang-Zhang urethroplasty and modified Koyanagi-Huang-Zhang urethroplasty.The long-term follow-ups included voiding function,penile appearance and sexual functions.Results Among 2068 children undergoing urethroplasty during the same period,a total of 133 children(6.4%)fulfilled the inclusion criteria.The medium-term follow-ups were conducted(n=126,94.7%)and 7 cases became lost to follow-ups.There were urethral fistula(n=5),urethral dehiscence(n=20),urethral stenosis(n=3),recurrent ventral curvature(n=10)and multiple malformations(n=8),including urethral dehiscence&fistula(n=1),urethral dehiscence with recurrent ventral curvature&urethral dehiscence(n=6)and fistula&urethral diverticulum(n=1).Average urinary flow rate was(8.4±2.6)ml/s and maximal flow rate(16.6±4.1)ml/s.The HOSE score of group Koyanagi-Huang-Zhang urethroplasty was(14.11±1.44)and the overall incidence of urethral complications 39.28%(33/84).The HOSE score of group modified Koyanagi-Huang-Zhang urethroplasty was(14.45±1.04)and the overall incidence of urethral complications 30.95%(13/42).No inter-group statistical difference existed except for incidence of urethral dehiscence.Long-term follow-ups were conducted(n=46,52.9%)and 41 cases lost follow-ups.The mean follow-up period was 5.92 years and the mean age at the last follow-up was 9(6.6-18.4)years.And there were voiding dysfunctions(15.22%),satisfactory penile appearance(54.35%)and generally satisfactory penile appearance(45.65%).None had penile erectile dysfunction or painful erection.Conclusion Koyanagi-Huang-Zhang urethroplasty and its modified techniques are effective for one-stage repair of proximal hypospadias.They may simplify procedures and achieve decent medium-to-long-term outcomes.However,we should pay greater attention to preventing urethral dehiscence.