【作者】 刘殿勇；

【导师】 杨进益；

【作者基本信息】 大连医科大学 ， 外科学， 2009， 硕士

【摘要】 目的:对比分析保留尿道板睾丸鞘膜代白膜阴茎伸直术与既往所采用的阴茎背侧白膜紧缩术和阴茎白膜V-Y皮瓣等阴茎伸直术式治疗重度阴茎下弯的手术效果。并对两组阴茎伸直方法结合Snodgrass尿道成形术术后临床效果、并发症的差异,进行临床研究,了解不同术式对治疗重度阴茎下弯的效果,从临床方面对保留尿道板睾丸鞘膜代白膜治疗重度阴茎下弯的尿道下裂做出评价,为提高尿道下裂治疗效果提供参考。方法:选取大连市儿童医院泌尿外科2007年1月～2008年12月收治重度尿道下裂患儿12例,采用保留尿道板睾丸鞘膜代白膜阴茎伸直术,作为试验组。年龄0.8岁至5岁之间男孩,体重8公斤至18公斤。12例均为首次接受手术治疗患儿。阴茎下弯程度均大于35°。记录患儿的年龄、体重、阴茎伸直前后下弯角度、伸直前后阴茎的长度、缺损尿道长度、术后阴茎下弯、尿瘘、尿道狭窄、尿道憩室等手术并发症。另取2005年1月～2007年12月收治的重度尿道下裂,采用阴茎被膜紧缩阴茎伸直术和V-Y皮瓣法阴茎伸直术共23例,作为对照组。实验组12例阴茎伸直后6个月行Snodgrass尿道成形术,对照组23例中13例为阴茎被膜紧缩阴茎伸直术后一期结合Snodgrass尿道成形术,10例采用V-Y皮瓣法阴茎伸直术术后6个月行Snodgrass尿道成形术。对照组23例患儿采取两种不同的阴茎伸直在术前术后观察指标和随访项目上没有明显差异。术前术后阴茎下弯角度、阴茎长度、缺损尿道长度的比较。术后随访时间3个月～6个月,平均4.5个月,术后随访项目包括阴茎下弯、尿瘘、尿道狭窄、尿道憩室等并发症,术后整体外观、排尿情况是否满意。将阴茎的外观形态无阴茎下弯、阴茎头形状良好、包皮分布均匀、尿道口位于龟头部、尿后有无滴沥、无尿流喷洒、无尿痛等记为满意。结果:两组病例在年龄、体重、术前所观察的阴茎下弯角度、缺损尿道长度及阴茎长度上比较没有明显差异(P>0.05),具有可比性。术后观察指标上,实验组阴茎下弯角度0°,均完全矫正,缺损尿道长度3.3～4.0cm,平均3.64±0.23cm,阴茎长度2.2～5.2cm,平均3.60±0.85cm。对照组阴茎下弯0°～15°,平均4.67±4.71°,缺损尿道长度2.4～3.6cm,平均2.95±0.29cm,阴茎长度2.6～5.5cm,平均3.21±0.65cm。从术后所观察的两组病人在阴茎下弯角度、缺损尿道长度及阴茎长度上比较具有显著性差异(P<0.05),说明实验组在矫正阴茎下弯上较对照组具有明显优势,并且一定程度上增加了阴茎的长度,虽然缺损尿道长度随之增加,但降低了尿道板的张力。尿道成形术后并发症及满意度:实验组尿瘘发生2例,1例发生在冠状沟,1例在阴茎体部,无尿道狭窄发生。对照组发生阴茎下弯6例(包括单纯下弯2例,合并尿瘘、尿道狭窄的4例),尿瘘6例,4例发生在冠状沟,2例发生在阴茎体部;尿道狭窄2例,1例位于龟头部尿道口,1例位于冠状沟。两组并发症比较,实验组并发症明显少于对照组(P<0.05)。两组尿道成型术后随访3个月到6个月,平均4.5个月,整体满意度实验组为91.7%,对照组为73.9%。两组对整体外观还是比较满意,不满意主要集中在阴茎下弯未完全矫正和尿瘘、尿道狭窄上。实验组患儿11例排尿通畅,无喷洒,1例患儿对尿瘘发生不满意。对照组17例总体上满意,排尿通畅,4例病人对术后勃起后阴茎下弯矫正不满意,4例对尿瘘、尿道狭窄不满意(其中2例伴有阴茎下弯)。结论:保留尿道板的睾丸鞘膜代白膜阴茎伸直术可以将阴茎下弯充分矫正,延长阴茎长度,延长尿道板,减少尿道板张力,不改变阴茎周径,减少术后阴茎下弯复发、尿瘘、尿道狭窄、尿道憩室等并发症的发生。睾丸鞘膜作为移植物保留了血管蒂,并且鞘膜面积大,无张力缝合于阴茎海绵体腹侧白膜上,不会产生鞘膜的缺血、坏死、挛缩等,可以使阴茎下弯充分矫正,防止复发,从而提高尿道成形术的成功率。更多还原

【Abstract】 Purpose: To compare and analyze the outcome of using tunica vaginalis(TV) for correction of chordee with 2 other traditional approaches : dorsal plication and V-Y flap incision of albuginea. To analyze the clinical efficiency and complications of three techniques in repairing the severe chordee: tunica vaginalis institution and 2nd-stage Snodgrass, dorsal albuginea plication(DAP), V-Y flap procedure and 1st-stage Snodgrass. To further assess TV procedure in repairing severe chordee and provide some references for hypospadias treatment.Methods: Group A:12 boys, aging from 0.8 to 5 years, weighing from 8 to 18 kilograms, with severe hypospadias were received in Dalian Children’s Hospital from January 2007 to December 2008. 12 cases underwent operation for the first time. The degree of penile curvature is greater than 35°. The information on age, weight, the degree of ventral chordee, the preoperative and postoperative length of corpora and the defect of urethra, the complications including recurrent curvature, fistula, urethral stricture and diverticulum were recorded in detail. Group B: 23 boys with severe hypospadias were received in Dalian Children’s Hospital from January 2007 to December 2008. Group A received TV procedure 1st-stage and 2nd-stage Snodgrass 6 months later. Group B: 23 boys underwent DAP procedure or V-Y flap procedure, 13 of which did DAP and Snodgrass simultaneously, 10 did 1st-stage V-Y flap procedure and 2nd-sondgrass 6 months later. The preoperative and postoperative curved degree, the length of penis and defect of urethra were compared. All patients were followed-up for 3~6 months (average 4.5). The follow-up focuses on curvature, urethral fistula, stricture and diverticulum, the cosmetic appearance of penis and glans, the voiding situation. The satisfying form is not only cosmetic but functional result as well. The recovery standard is: no curved penis, natural appearance of corporal body, glans and meatus, well distributed prepuce, no dysuria, dribbling, spraying.Results:There is no significant difference between two groups in ages, weights, the preoperative degree of chordee, the length of urethral defect or corpora(P> 0.05). The curvature has all been corrected in group A. The urethal defect was from 3.3~4.0cm( median3.64±0.23). The length of corpora was 2.2～5.2cm (median 3.60±0.85). The degree of curvature was from 0°～15°in group B (median 4.67±4.71°). The urethal defect was from 2.4～3.6cm(median 2.95±0.29). The length of corpora was 2.6cm～5.5cm (median 3.21±0.65cm). There is significant difference(P<0.05) between group A and group B in correcting the degree of chordee, the length of urethral defect and corpora. TV procedure has great advatages in penile lengthening,morever, it reduces the tension of urethral plate although it increases the length of urethral defect. Postoperative complications and satisfactions. Group A: 2 fistulas (1 coronary sulcus, 1 corporal body), no stenosis. Group B: 6 cases showed recurrent curvature (simple curvature in 2, associated with fistula and stricture in 4). 6 cases occurred fistula ( 4 coronary sulcus, 2 penile body). 2 cases suffered stricture(1 meatal stenosis, 1 coronary sulcus). There is significangt difference in complications between two groups (P< 0.05). All patients were followed-up for 3~6 months (average 4.5months). The degree of satisfaction: group A 91.7%, group B 73.9%. The two groups were satisfied in the corporal appearance. 11 cases in group A void fluently, no urine spray. 1 was not satisfied with fistula. 17 cases in group were satisfied with the operation. 4 cases were not satisfied with straight erections. 4 cases complained fistula and stricture (2 associated with chordee).Conclusions: TV procedure is safe and effective in the correction of severe chordee, lengthening urethra, decreasing the urethral tension without changing the corporal circumference, especially avoiding many complications, such as recurrent curvature, fistula, stricture and diverticulum. TV with sufficient vascular supply is large enough for tailoring, which is impossible to cause graft necrosis, ischemia and contracture. TV procedure has advantages on correcting chordee completely, preventing recurrent chordee and improving the success rate.更多还原