改良Kulkarni法一期舌黏膜尿道成形术治疗前尿道狭窄的疗效

The outcomes of modified Kulkarni's one-stage tongue mucosa graft urethroplasty in patients with anteriorurethral stricture

目的探讨改良Kulkarni法一期舌黏膜尿道成形术治疗前尿道狭窄的疗效。方法回顾性分析2020年1月至2022年12月上海市第六人民医院应用改良Kulkarni法一期舌黏膜尿道成形术治疗的42例前尿道狭窄患者的临床资料。患者年龄(48.1±16.2)岁。21例既往有尿道成形手术史。医源性尿道狭窄15例,外伤性尿道狭窄5例,感染性尿道狭窄6例,硬化性苔藓样病变11例,特发性尿道狭窄5例。狭窄长度(6.4±3.0)cm。两段狭窄11例,多段狭窄3例。术前最大尿流率(4.6±2.3)ml/s,残余尿量(96.6±24.7)ml。采用会阴部切口,切开皮肤、皮下组织,将阴茎逆向脱套褪出会阴部切口,显露整个前尿道,直视下将尿道狭窄段左侧纵行剖开,取合适长度舌黏膜补片修补尿道狭窄段。本研究术式改良:①移植物采用舌黏膜,不是颊黏膜;②对累及尿道外口的狭窄,将尿道外口左侧切开,与远端狭窄段左侧剖开切口相连续,然后一体使用舌黏膜成形。术后1个月拔除导尿管,观察排尿情况,行尿流率检查。拔管后1、3、6个月复查尿流率,然后每年随访尿流率1次。结果本研究42例手术均顺利完成,手术时间60~120min,围手术期无输血,无感染、组织坏死、出血等并发症。16例主诉有口腔疼痛,予对症治疗,均于术后1周内缓解。随访期间39例排尿通畅,拔管后1、3、6个月最大尿流率分别为(25.6±5.7)、(25.3±5.7)、(24.8±5.9)ml/s,残余尿量分别为(11.3±7.1)、(11.9±7.5)、(12.4±7.9)ml。3例拔管后即刻能自行排尿,但随访期间狭窄复发,其中2例为术后2个月出现狭窄复发,1例行尿道扩张后恢复排尿通畅,1例经过2次尿道扩张后仍狭窄复发,行尿道成形术后治愈;1例于术后3个月狭窄复发,行尿道扩张后排尿通畅。本组患者随访6~42个月,无局部伤口感染、尿道皱缩、尿道憩室、尿瘘发生。结论改良Kulkarni法一期舌黏膜尿道成形术可用于治疗前尿道狭窄,成功率高、并发症少,可避免发生局部伤口并发症。

Objective e To evaluate the efficacy of modified Kulkarni's one-stage tongue mucosal urethroplasty.Methods From January 2020 to December 2022,42 patients with anterior urethral stricture treated by modified Kulkarni one-stage tongue mucous urethroplasty in Shanghai Sixth Peoples Hospital.Stricture etiology was iatrogenic in 15 cases,trauma in 5 cases,unknown in 5 cases,infection in 6 cases,and lichen sclerosus in 11 cases.Twenty-one patients had previously undergone urethroplasty.The mean age of patients was(48.1±16.2)years.Median stricture length was(6.4±3.0)cm,including 11 cases with two strictures and 3 cases with multiple stenoses.The average preoperative Qmax was(4.6±2.3)ml/s,and the average residual urine was(96.6±24.7)ml.For treatment methods,a midline perineal incision was made,penis was invaginated into the incision,the distal extent of the stenosis was identified,urethra was rotated and dissected only on the left side,and incised dorsally to expose the whole stricture longitudinally.The tongue mucosal graft was fixed to the underlying albuginea and the right margin of the graft was sutured to the left margin of the urethral plate.Foley F14 silicon catheter was inserted.The urethra was rotated to its original position thus covering the oral graft.The improvements were as follows:First,we used tongue mucosa instead of cheek mucosa;Second,for the stenosis involving the urethral meatus,the narrowed urethral meatus was incised on the left side,which was continuous with the incision on the left side of the distal narrow segment,and then tongue mucosa was used as a whole.The catheter was removed 4 weeks after surgery,followed up 1,3,6 months,and then once a year.Results All 42 patients underwent successful surgery without blood transfusion during the operation.The surgical time was 60-120 minutes.There were no complications such as infection,tissue necrosis,or bleeding during the perioperative period,and 16 patients complained of oral pain,which was relieved within one week after surgery.During the follow-up period,39 cases presented with unobtrusive urination.One month after extubation,the maximum urine flow rate was(25.6±5.7)ml/s,and the residual urine volume was(11.3±7.1)ml.Three months after extubation,the maximum urine flow rate was(25.3±5.7)ml/s,and the residual urine volume was(11.9±7.5)ml.Six months after extubation,the maximum urine flow rate was(24.8±5.9)ml/s,and the residual urine volume was(12.4±7.9)ml.Two patients had recurrent stenosis 2 months after surgery,of which 1 patient underwent urethral dilation and recovered unobstructed urination,and 1 patient had recurrent stenosis after urethral dilation for 2 times and was cured after urethroplasty.No local wound infection,urethral shrinkage,urethral diverticulum,or urinary fistula occurred during the follow-up for 6 to 42 months.Conclusions The modified Kulkarni's one-stage tongue mucosa graft urethroplasty is suitable for most anterior urethral strictures,with high success rate,few complications,and avoidance of local wound complications.