改良York-Mason术式在前列腺癌术后并发尿道直肠瘘修复中的应用价值

Application of modified York-Masonprocedurein repairing urethrorectal fistula following radical prostatectomy

目的探讨采用改良York-Mason术式治疗前列腺癌术后并发尿道直肠瘘的疗效。方法回顾性分析2016年5月至2022年10月上海第六人民医院收治的20例前列腺癌术后并发尿道直肠瘘患者的临床资料,年龄(76.6±4.2)岁。患者临床表现为排尿时伴尿液从肛门溢出,合并膀胱颈口狭窄2例,尿失禁1例。3例有前列腺癌术后放疗史。尿道直肠瘘病史(1.8±2.3)年。术前尿道造影检查示造影剂从膀胱颈部溢出流入肠道。3例可疑患者加做CT三维重建可见瘘口。尿道镜检查可见膀胱颈部有凹陷。5例行肛门镜检查见直肠下端前壁有气泡形成,伴有直肠前壁凹陷;瘘口至肛周距离(6.0±2.1)cm,瘘口直径≥1cm12例,<1cm8例。术前12例已行膀胱造瘘,17例已行横结肠造瘘。本组20例均采用改良York-Mason术式治疗全麻,患者取俯卧折刀位,将臀部分开固定以显露肛门。从尾关节旁2点处至肛门边缘做一8 cm长旁正中皮肤切口,此为改良York-Mason入路。切开肛门括约肌后,两侧括约肌分别用3-0铬缝线标记。显露尿道直肠瘘口,用4-0可吸收线缝合尿道侧瘘口,3-0可吸收线缝合直肠前壁侧瘘口。将3-0铬缝线标记的浅、深肛门括约肌收紧打结,重建肛门括约肌。2例伴膀胱颈部狭窄者行尿道内切开。术后3d拔除肛周切口引流管,导尿管均留置3周。有结肠造瘘者术后可进普食;无结肠造瘘者术后禁食5d,应用静脉营养。结果本组20例手术均顺利完成,术中无并发症。术后随访10~48个月,17例排尿通畅,最大尿流率>15ml,未见尿液从肛门溢出。15例术后复查尿道造影和尿道镜检查,无尿道直肠。所有患者术后未出现大便失禁。3例仍有肛门漏尿,其中1例术后3个月再次行改良York-Mason术后治愈;2例有放疗史患者,其中1例经过再次留置尿管2周后,肛门渗液消失,另1例仍有肛门漏尿,患者因高龄体弱放弃进一步治疗。1例排尿困难者定期尿道扩张。本组20例中,15例控尿基本满意,无需尿垫;4例每天需用尿垫1~3块;1例为完全尿失禁。结论改良York-Mason术式治疗前列腺癌术后并发尿道直肠瘘是安全、有效的,手术成功率高,并发症少。

Objective To investigate the effect of modified York-Mason technique on urethrorectal fistula after radical prostatectomy.Methods A retrospective analysis of clinical data from 20 patients with urethrorectal fistula after radical prostatectomy admitted to Shanghai Sixth Peoples Hospital from May 2016 to October 2022 was conducted.Patients'average age was(76.6±4.2)years.The etiology was rectal injury during radical prostatectomy.Patients present urine leakage from the anus during micturition.2 cases also had bladder neck stenosis,and 1 case had urinary incontinence.3 cases had radiotherapy history because of prostate cancer.The average duration of urethrorectal fistula was(1.8±2.3)years.Preoperative imaging confirmed the presence of contrast agent flowing from the bladder neck into the rectum.Three suspicious patients also underwent CT three-dimensional reconstruction.Urethroscopy revealed a depression at the bladder neck in five cases.Anorectal examination in five cases showed the formation of gas bubbles in the lower anterior wall of the rectum,along with a concave anterior wall.The distance from the fistula to the anal margin was(6.0±2.1)cm,with fistula diameters≥1 cm in twelve cases,<1 cm in eight cases.Twelve patients had previously undergone cystotomy,and seventeen patients had undergone colostomy.The modified York-Mason procedure was adopted for all 20 cases.The patients were under general anesthesia and placed in the prone jackknife position,with the buttocks spread and fixed to the sides to expose the anus.An 8 cm-long incision was made from two points near the sacrococcygeal joint to the anal edge,representing the modified York-Mason approach.After dividing the anal sphincter muscle,both sides were marked using 3-O chromium thread for subsequent anal reconstruction.The urethrorectal fistula was exposed,and the urethral side of the fistula was sutured with 4-O absorbable thread,while the anterior rectal wall side was sutured with 3-O absorbable thread.In cases of bladder neck stenosis,urethral internal incision was performed,and a urethral catheter was retained for 3 weeks postoperatively.Perianal incision drainage tubes were removed after three days.Patients had colostomy repair could eat the day after surgery,while those who didn't were fast for five days and received intravenous nutrition.Results All 20 cases in this group were successfully completed without complications during surgery.Follow-up ranged from 10 to 48 months after surgery.Seventeen(17/20)cases had unobstructed urination,with a maximum urine flow rate>15 ml,and no urine leakage from the anus.Postoperative urethrography and cystourethroscopy showed there were no urethrorectal fistulas in 15 cases.None of the patients experienced fecal incontinence after the surgery,except for three patients with a history of radiotherapy who continued to experience anal leakage.One patient underwent a second modified York-Mason procedure and achieved complete recovery three months after the second surgery.Another patient had anal discharge,and the fistula healed after two weeks of urethral catheter retention.One patient refused further treatment due to advanced age and frailty but still had anal leakage.Another patient experienced regular urethral dilation for urination difficulties,while one patient continued to have urinary incontinence.Conclusions The modified York-Mason technique could be an effective method for urethrorectal fistula after radical prostatectomy with high success rate and few side effects.