人工海绵体和人工括约肌同期植入术治疗创伤性后尿道狭窄术后重度勃起功能障碍和重度尿失禁的效果

Effect analysis of simultaneous implantation of artificial cavernous body and sphincter in patients with severe erectile dysfunction and urinary incontinence after traumatic posterior urethral stricture

目的探讨同期行人工阴茎海绵体和人工尿道括约肌植入术治疗创伤性后尿道狭窄术后重度勃起功能障碍和重度尿失禁的效果。方法去回顾性分析2021年1月至2022年12月南部战区总医院收治的创伤性后尿道狭窄患者3例,年龄分别为42,32,28岁。均为外伤后致骨盆骨折、后尿道断裂狭窄,例2左下肢缺失,例3右下肢缺失。患者均表现为排尿困难,自述无勃起感觉。术前膀胱尿道造影检查示后尿道狭窄,长度分别为2、2、3cm。夜间勃起功能测试均无勃起反应,均为重度勃起功能障碍。后尿道狭窄经狭窄段切除端端吻合手术治愈,尿道通畅。术后再次行夜间勃起功能测试提示仍为重度勃起功能障碍,予西地拉非和他达拉非治疗3个月。国际勃起功能问卷表评分为1、2、2分,阴茎夜间勃起功能测试仍无有效勃起,为重度勃起功能障碍。术后控尿功能差,每日应用尿垫数量分别为6、6、8块,采用盆底康复训练6个月,尿动力学检查均提示重度压力性尿失禁,1 h尿垫试验结果分别为30、32、82g。3例均行人工阴茎海绵体和人工尿道括约肌同期植入手术。全麻,患者取平卧蛙式位。于阴囊上部做横切口,首先分离尿道,将人工尿道括约肌袖套套入。再分别行左右两侧阴茎海绵体窦扩张,测量海绵体长度,选择合适的人工阴茎海绵体分别植入。将水囊分别置于耻骨后膀胱前间隙,将控尿开关置于阴囊上方,勃起开关置于阴囊下方。测试控尿和勃起功能正常后关闭切口。结果3例手术均顺利完成。人工阴茎海绵体和人工尿道括约肌同期植入手术时间分别为270、260、240min。术后1周拔除尿管,术后2周开始训练使用勃起开关,1周后3例均可自控达到充分勃起。术后6周激活控尿开关,3例均控尿正常,无需尿垫。随访12~18个月,2例勃起和控尿功能正常;1例术后2个月出现尿道腐蚀,在充分抗感染的基础上行原人工括约肌全套取出、尿道修复,同期植入新的人工尿道括约肌,手术顺利,再次术后随访1年,控尿和勃起功能正常。结论同期行人工阴茎海绵体和人工尿道括约肌植入手术治疗创伤性后尿道狭窄术后重度勃起功能障碍和重度尿失禁,可以缩短手术周期时间,减少费用,减少创伤,效果确实,但对患者的经济、心理、身体情况,以及术者的技术条件要求高,手术复杂、风险大,仅合适有条件的单位开展。

IObjective To discuss the effect of simultaneous implantation of artificial cavernous body and urethral sphincter for severe erectile dysfunction and urinary incontinence after traumatic posterior urethral stricture.Methods A retrospective analysis was performed on 3 patients with traumatic posterior urethral stricture admitted to the Southern Theater General Hospital from January 2021 to December 2022,aged 42,32,28 years old,all of whom suffered pelvic fracture and posterior urethral stricture after trauma.Patient 2 were missing left lower limb and patient 3 were missing right lower limb,all of whom had dysuria.Preoperative cystourethrography indicated posterior urethral stricture with a length of 2,2,3 cm,respectively.No erectile response and severe erectile dysfunction were reported in penile nocturnal erectile function tests.Posterior urethral stricture was cured by end-to-end anastomosis surgery.After urethral stricture was cured,the nighttime erectile function test indicated severe erectile dysfunction and diagnosed erectile dysfunction and urinary incontinence.After 3 months of continuous administration of sildenafil and/or tadalafil,the erectile dysfunction did not improve,and the score of the international erectile function test was 1,2,2 points.Severe erectile dysfunction.The urine could not be controlled,the number of urine pads per day was 6,6,8,respectively,and pelvic floor rehabilitation training was adopted for urinary incontinence.6 months later,urodynamic examination indicated severe stress incontinence,and the urine pad test was 30g,32g,and 82g per hour.Patients were fully informed of the surgical risks before surgery.Simultaneous implantation of artificial penile cavernous body and artificial urethral sphincter were performed after full preoperative preparation:General anesthesia,supine frog position with transverse incision in upper scrotum,the urethra was separated and the artificial urethral sphincter cuff was easily inserted into the upper scrotum.Then the left and right sides of the penis cavernous sinus were dilated and the length of the cavernous body was measured.Suitable artificial penis cavernous body was implanted,water sacs were placed in the posterior pubic space and the anterior vesical space,and the tubes were connected.The erectile switch was placed under the scrotum,and the incision was closed after repeated testing of urine control and normal erectile function.Results Three cases were successfully completed.The simultaneous implantation time of artificial cavernous body and artificial urethral sphincter was 270,260,240 min,respectively.The catheter was removed 1 week after surgery,and the erection switch was trained 2 weeks after surgery,and full erection was achieved after 1 week.The urine control switch was activated 6 weeks after surgery,and urine control was normal without urine pad.Following up for 12 to 18 months,2 cases had normal erections and urinary control,1 case had urethral corrosion 2 months after surgery,the original artificial sphincter was removed completely and a new artificial urethral sphincter was implanted in the same period,the operation was successful,and the follow-up was 1 year,urine control and erectile function returned to normal.Conclusions For the severe erectile dysfunction and severe urinary incontinence after traumatic posterior urethral stricture,simultaneous implantation of artificial penile cavernous body and artificial urethral sphincter could be alternative choice.