【作者】 李鹏程；

【导师】 李森恺； 李强；

【作者基本信息】 中国协和医科大学 ， 整形外科， 2008， 博士

【摘要】 1.微粒粘膜-明胶海绵复合移植预制尿道的实验研究尿道下裂是常见的男性泌尿生殖系统先天性畸形,尿道组织缺损是其主要特征之一。使用自体组织再造尿道存在供区继发畸形的问题,我们拟利用明胶海绵与微粒口腔粘膜复合移植于皮下纤维包膜,并利用扩张器支撑,预制以粘膜为衬里的腔穴以替代尿道。目的:探讨明胶海绵复合微粒粘膜移植于扩张器包膜上的成活情况和转归。并测量其挛缩情况。采用加入骨髓间充质细胞,耦合皮瓣等方法以对抗挛缩,并观察其效果。材料和方法:1.将口腔粘膜剪成粘膜微粒,直径＜1mm。试验组以4:1,8:1,16:1,的面积比例移植,分为Ⅰ组、Ⅱ组和Ⅲ组。将微粒粘膜均匀涂抹于明胶海绵上,然后移植于扩张器包膜上,扩张器不去除,关闭切口,使扩张器内压强约有40mmHg,对照组不加微粒粘膜。术后1周、2周、3周、4周行大体观察及HE染色,免疫组织化学染色。第4周行扫描电镜观察。术后5月再次取材观察植入粘膜的转归。2.测量挛缩情况时候,预制纤维包膜形成后,实验组:Ⅴ组白体微粒粘膜扩张面积比例8:1;Ⅵ组在Ⅴ组基础上加入骨髓间充质细胞;Ⅶ组植以腹股沟处全厚皮,Ⅷ组微粒粘膜耦合局部皮瓣。Ⅸ组空白对照。在支撑3周,每周给予清洁换药处理,3周后取下支撑管,测量挛缩情况。结果:1.术后一周可见粘膜散在存活,上皮细胞长入明胶海绵内,各组创面未完全愈合。不同组别之间愈合率有差别。术后二周可见扩张器包膜表面粘膜成活。Ⅰ组、Ⅱ组创面愈合率在90%以上,Ⅰ组、Ⅱ组优于Ⅲ组(P＜0.05)。Ⅰ组、Ⅱ组间差别无统计学意义。3周时各实验组创面愈合率均达90%以上。Ⅰ组、Ⅱ组较在2周、3周时无明显差别。Ⅲ组不同时间有差异(P＜0.05)。各组在2周时的愈合率与1周时有明显差异(P＜0.01)。2.各实验组在前4周角蛋白抗体免疫组化染色均为阳性,证实为上皮组织。不同比例组别上皮厚度有差别。术后3周时为上皮为复层鳞状上皮,细胞呈极性排列。术后5月时候植入细胞排列失去极性,角蛋白抗体免疫组化染色为阴性。3.明胶海绵在术后1周时,未见明显吸收。术后4周时仍见部分明胶存留。4.各组均有挛缩现象,Ⅷ挛缩最轻,感染最少。结论:1.微粒粘膜-明胶海绵复合移植在扩张器包膜上可以形成粘膜衬里;2.微粒粘膜-明胶海绵复合移植在密闭的扩张器包膜内后,2～3周上皮质量最好,随时间延长,上皮细胞出现退化。3.复合移植可以增加上皮的厚度。明胶海绵的支架作用可能是上皮层数增多的原因,但是明胶降解较慢,有待寻找降解速率更快的支架材料。4.微粒粘膜-明胶海绵复合移植在与外界相通的纤维包膜内,硅胶管支撑3周,取出支撑管后,伤口会挛缩。2.微粒粘膜-明胶海绵复合移植耦合局部皮瓣再造尿道的临床研究目的:尿道下裂是一种常见的男性泌尿生殖系统的先天性畸形,手术是唯一的治疗方法。onlay island flap法及Snodgrass法并发症少、术后外观形态好,近年来日趋盛行。适用于修复不伴有阴茎弯曲的远端型尿道下裂。然而对于伴有阴茎下弯的近端型尿道下裂患者,尚无很好的手术方法。本研究主要探讨微粒包皮内板粘膜或尿道板粘膜游离移植耦合局部皮瓣治疗重型小儿尿道下裂的手术疗效。并与阴囊皮片耦合局部皮瓣再造尿道进行了比较。方法:自2006年4月～2007年12月,同一名外科医生实施了18例需要切开尿道板的阴茎阴囊型尿道下裂和阴囊型尿道下裂。Ⅰ组共应用微粒包皮内板粘膜或尿道板粘膜游离移植耦合局部皮瓣治疗重型尿道下裂8例,一期治疗了7例阴茎阴囊型和阴囊型尿道下裂患者,对1例尿道外口位于阴囊近端的重度尿道下裂行二期修复。Ⅱ组10名患者接受了阴囊皮片游离移植耦合包皮岛状瓣再造尿道手术。阴茎阴囊型7例均一期手术,阴囊型3例均采用分期手术。所有患者一期手术者术后用带侧孔软弹硅胶支撑管支撑再造尿道14天,二期手术者用硅胶支撑管支撑再造尿道6个月,行尿道吻接术。门诊定期随访对手术效果进行临床评估。术后部分患者行尿道镜检查。结果:全组18例尿道下裂初治病例中,Ⅰ组术后随访2～24个月,Ⅱ组随访6～30个月,两组均无尿道狭窄发生。Ⅰ组手术时间150±35.0 min,Ⅱ组手术时间200±45.0min,手术中测量修复尿道缺失长度2.5cm～4.5cm(平均3.38±0.79cm)。所有患者阴茎下弯彻底矫正,新建尿道口位于阴茎头部,呈纵向裂隙状开口,阴茎外观类似于包皮环切术后的形态,能正常勃起和站立排尿。Ⅰ组、Ⅱ组,均有1例阴茎阴囊型尿道下裂患者术后一年出现轻度阴茎下弯,未行治疗。Ⅰ组1例术后并发针尖状尿瘘,1月内自愈。Ⅱ组1例新建尿道口裂开后移,需再手术。两组总的并发症率无显著差别。手术时间有差别。两组各随访2例尿道镜,两组尿道镜显示:尿道镜见Ⅰ组尿道管腔为接近圆形,尿道壁光滑,粘膜色粉红,环形皱襞规则,柔软顺应性好;Ⅱ组再造的尿道为横椭圆形,尿道壁软而顺应性较好。结论:微粒包皮内板粘膜或尿道板粘膜游离移植耦合局部皮瓣可以用于治疗重型尿道下裂。其近期并发症发生率与Ⅱ组接近。新建尿道受到海绵体的支撑作用,不易发生扭曲,吻合口处尿道板不予切除,不易发生吻合口狭窄。手术后无需进行尿道扩张。术后新建尿道口呈纵形裂隙状开口,成形后的阴茎头外观令人满意。再造尿道光滑,尿道内未见生长毛发。应用本法成形远端尿道其优点在于减少局部皮肤应用,改善成形龟头外观,减少了尿道并发症。但由于我们随访时间尚短,其长期效果尚需进一步观察。更多还原

【Abstract】 1.Prefabricated urethra with oral micro-mucosa and gelatin spongeHypospadias is one of the most common congenital deformities of male genitourinary system.Distal urethral defect is the main manifestation.Urethral reconstruction requires adequate amounts of tissue and donor-site morbidities occured common by using autologus tissue.We graft the gelatin sponge together with micro-mucosa which taken from buccal mucosa to the subcutaneous capsule.Then we implant soft tissue expander under the graft to prefabricate the urethra lined by mucosa.Objective:We investigated the survival and inversion of the compound graft(gelatin sponge and micro-mucosa) to the capsule and measure the rate of contracture.Further study were also made to against the contracture such as adding BMSC and combining with flap.Materials and methods:1.We cut the free buccal mucosa into particles,the diameter of which is less than 1mm, spread onto the gelatin sponge and then transplant to the capsule,the experimental group was divided into three subgroups(GroupⅠ,ⅡandⅢ) with area expansion ratio of autogenous micro-mucosa 4:1,8:1 and 16:1 respectively.We implant the soft tissue expander under it and keep 40mmHg in it.The control group was only implanted soft tissue expander without mucosa graft.Macroscopy and histological samples by HE and immunohistochemical staining were examined on the 7th,14th,21th and 28th day after the grafting.SEM examination was taken on the 28th day.We observed the tissue harvested from the samples on the 150th day after grating to investigate the inversion of the grafted mucosa.2.We prefabricate the capsule in advance when measure the contraction of grafts.5 groups(Ⅴ,Ⅵ,Ⅶ,ⅧandⅨ) were made.The autogenous micro-mucosa graft(expansion rate 8:1)was served as groupⅤgroupⅥwas the same ratio but adding BMSc.We transplanted free skin graft taken from groin in groupⅦand micro-mucosa combined with local flap in groupⅧ.GroupⅨwas blank control.All the groups were keeping stent for 3 weeks by the tubes and measured the contraction after 3 weeks.Results:1.All the wounds were not healed completely after one week grafting,though some of the mucosa survived and its epithelial cells grew into the gelatin sponge,and the wound healing rates were different.On the 14th day after grafting,The wound healing rates of groupⅠandⅡwere more than 90%and higher than groupⅢ(p＜0.05),however,there’s no obvious difference between groupⅠandⅡ.All the wound healing rates were more than 90%0 on the 21th day.There’s no obvious difference between 2 weeks and 3 weeks after grafting in groupⅠand groupⅡ,however groupⅢhad the difference(P＜0.05).All the three groups had the obvious difference between one week and two week after grafting(P＜0.01).2.The CK were observed with immuneohistochemistry in wound tissue specimens so as to confirm epithelial tissue among all the experimental groups before 4 weeks.We could find stratified squamous epithelium on 21th day and the cells presented obvious polarity. However,immunohistochemical staining of certain antibody were negative in 5 months after grafting and the polarity disappeared. 3.The gelatin sponge was not absorbed on the 7th day.We could also find some gelatin sponge exist 4 weeks after grafting.4.All the groups encountered the contraction,however groupⅧwas better than the others.Conclusion:1.The oral micro-mucosa and gelatin spongy graft can survive on the expanded capsule.2.The quality of compound graft is best between 2 weeks and 3 weeks after grafting. The cell degeneration can be found in the long time.3.We could find stratified squamous epithelium on 21th day and the cells presented obvious polarity.The stratified squamous epithelium is thick,because epithelial cells grew into the gelatin sponge.4.All the groups encountered the contraction after removing the silicone tubes. 2.Urethral reconstruction using gelatin spongy and micro-mucosa graft combined with local flapHypospadias is one of the most common congenital deformities of male genitourinary system and the surgical treatment is the only method for repairing hypospadias.Objective:It has been popular to repair hypospadias by using the tubularized incised plate(TIP) urethroplasty and onlay island flap urethroplasty in recent years because of their low complication rates and satisfied cosmetic and functional results.However,both of the urethroplasties are not applicable to proximal hypospadias with severe chordee.The purpose of our study is to contrive a new method to repair proximal hypospadias by combining micro-mucosa which taken from inner prepuce or urethral plate with local flap to reconstruct urethra and describe the clinical feasibility and value of this method. Moreover,we compare our method with the other ones such as combined use of scrotal skin graft and local flap.Methods:From April 2006 to December 2007,18 cases of congenital hypospadias were operated using our method by the same surgeon.The average age was 21 months old(8 months to 36 months).The meatus located at the penoscrotal angle or scrotum and deep chordee was all presented.We divided all the cases into 2 groups(8 cases in groupⅠand 10cases in groupⅡ).GroupⅠwere repaired by combined use of micro-mucosa which taken from inner prepuce or urethral plate and local flap to reconstruct urethra.Only one of the 8 cases was undergone two-staged operations because the meatus located at the proximal scrotum.GroupⅡwere repaired by combined use of scrotal skin graft and prepucial flap to reconstruct urethra.3 of the 10 cases were undergone two-staged operations.A free micro-mucosa was transplanted to the corpora cavernosa and covered with gelatin sponge.Temporary urethral stent tube which had lateral apertures were used for about 14 days after first operations and used for 6 months after second staged operations.All the patients were followed up and some of them were examined using urethroscopy postoperatively.Results:Patients in groupⅠwere followed up after surgical repair for 2～24 months and in groupⅡfor 6-30 months.All the cases were successful without urethral fistula and urethral stricture postoperatively.It took about 150±35.0 min of groupⅠand 200±45.0 min of group2 to complete this operation.The length of absent urethra was about 2.5cm～4.5cm (average length was 3.38±0.79cm) which measured during the operations.Both of the methods corrected the down curvature and created a vertically oriented,slit-like meatus at the tip of the glans and satisfactory voiding function.The appearance of penis resembled the appearance after prepuce circumcision.All the patients could normal urination and erection.Superficial penile curvature occurred in one case respectively of two groups after one year postoperatively without further repair.One case in groupⅠhad needle fistula but self-cure.The neomeatus of one case in groupⅡhad split and retruded so as to take further repair.there’s no obvious disparity of complication rates between two groups.2cases in either group were undergone urethroscopy follow-up.GroupⅠpresented smooth urethral wall,normal urethral caliber and good compliance.Conclusion:Our method could repair the proximal hypospadias which combined micro-mucosa taken from inner prepuce or urethral plate and local flap.The complication rates are approached to the groupⅡ.The neourethra was not easy to curvature because of the support of corpus cavemosum.We didn’t resect the urethral plate to avoid the stenosis of anastomosis and urethral expansion.A vertically oriented,slit neomeatus was gained after operation and the appearance of the glans was satisfied.Furthermore,hair growth couldn’t been found in the urethra after puberty.The advantages of our method are to decrease the utilization of local tissues,improve the appearance of glans and decrease the complication rates.However,the time of follow-up is not adequate,so we have to make further investigations after long peiod.更多还原