自体游离腹股沟真皮片移植在尿道下裂重度下弯矫治中的应用

Application of autologous free inguinal dermal patch graft in the correction of severe ventral curvature of hypospadias

目的探讨自体游离腹股沟真皮片移植在尿道下裂阴茎海绵体不对称所致重度下弯矫治中的应用效果。方法回顾性分析2018年2月至2019年12月郑州大学第一附属医院小儿外科收治的26例重度阴茎下弯的尿道下裂患儿治疗情况,患儿年龄范围为1.5~5.2岁,中位年龄为2.6岁。所有患儿均采用分期手术,第一期手术先给予阴茎皮肤肉膜脱套矫正浅筋膜所致的阴茎下弯,再横断尿道板解除引起阴茎下弯的因素,如阴茎下弯仍>30°,于最大腹侧弯曲处切开白膜,松解白膜与阴茎海绵体之间的Smith间隙,经人工勃起试验检测下弯矫治情况,如仍有下弯,继续松解Smith间隙直至阴茎勃起试验证实阴茎伸直满意,切取同等面积游离自体腹股沟真皮片覆盖阴茎白膜缺损区域。背侧包皮正中剪开后包绕覆盖至阴茎腹侧正中区域以备二期尿道成形使用,对于尿道下裂术后阴茎下弯者选择相应皮瓣覆盖阴茎腹侧以备下次尿道成形,比较阴茎伸直前后背侧、腹侧的长度。第二期手术采用腹侧尿道外口至龟头远端皮肤卷管成形尿道或自体唇黏膜镶嵌阴茎体后联合局部皮瓣耦合成形尿道,并覆盖周围筋膜或阴囊精索外筋膜,皮肤改形覆盖。在阴茎白膜切开前和白膜切开真皮瓣修补后分别测量阴茎腹侧和背侧的长度,采用t检验分析测量数据。结果26例一期手术患儿,阴茎下弯一期矫直满意,第一期手术中测得阴茎伸直前背侧长度为(35.6±3.1)mm,腹侧长度为(31.8±3.2)mm;伸直后阴茎背侧长度为(35.8±2.9)mm,腹侧长度为(35.6±3.1)mm;第二期术前阴茎背侧长度为(36.5±3.1)mm,腹侧长度为(36.3±2.9)mm。比较手术前后阴茎腹侧长度,差异有统计学意义(P<0.05)。术后无阴茎腹侧血肿、下弯复发等现象,二期手术出现1例尿道瘘,无尿道狭窄、伤口裂开、尿道憩室等发生。结论应用自体游离腹股沟真皮片移植技术可以充分矫正尿道下裂阴茎海绵体不对称所致的阴茎下弯,并可延长阴茎长度。

Objective To explore the effect of autologous free inguinal dermal patch grafting for severe chordee caused by an asymmetry of cavernous body of penis in hypospadias.Methods From February 2018 to December 2019,retrospective analysis was performed for 26 hypospadiac children with severe chordee due to cavernous body asymmetry.The median age was 2.6(1.5-5.2)years.During the first stage,skin flap was harvested for correcting penile chordee and then urethral plate transected for removing the causative factors of penile chordee.If ventral curve persisted over 30°,incision of tunica albuginea was made at ventral maximum bend,Smith space liberated between tunica albuginea and cavernosa and ventral curve degree measured by artificial erection test.Smith space was further released until satisfactory penile straightening.Same area of free inguinal dermal flap was grafted for covering the defect of tunica albuginea.Then dorsal prepuce was cut in middle and wrapped for covering ventral median area of penis for secondary urethroplasty.For severe ventral curve after repair,skin flap was selected for covering ventral side of penis.Dorsal and ventral length of penis were measured and compared before and after dermal patch graft.During a second stage,urethra was shaped by local skin coiling from primary orifice to distal glans or by autologous mucosa inlaying onto penile body plus local skin flap and surrounding fascia or external spermatic fascia of scrotum was covered on reconstructed urethra.The rest of penile skin was covered at ventral side of penis.The length of ventral and dorsal penis was measured before and after albuginea incision and flap repatching.And t-test was utilized for analyzing the measurements.Results Among 26 cases,penile length increased significantly.During primary operation,penile length pre-extension was(35.6±3.1)mm at dorsal side and(31.8±3.2)mm at ventral side.After extension,penile length was(35.8±2.9)mm at dorsal side and(35.6±3.1)mm at ventral side.Prior to a second stage,dorsal penile length was(36.5±3.1)mm and ventral length(36.3±2.9)mm,suggesting that the difference in length of ventral side before and after operation was statistically significant(P<0.05).There was no recurrence of ventral penile hematoma after the first stage operation.After a second stage,there was 1 case of urethral fistula and no urethral stricture,wound dehiscence or urethral diverticulum was noted.Conclusions Autologous free inguinal dermal patch graft can fully correct penile chordee due to an asymmetry of cavernous body in hypospadias.Penile length may be lengthened.