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先天性阴茎下弯腹侧矫直技术的有效性观察

2009-03-30李养群黄循镭段晨旺李森恺

中国美容医学 2009年2期

陈 斌 李养群 李 强 黄循镭 段晨旺 李森恺

[摘要]目的:探讨先天性阴茎下弯腹侧矫直技术的效力。方法:对本院2000年3月到2008年8月收治的12例(3~27岁,平均6.5岁)不同程度先天性阴茎下弯患者分别采用包皮脱套,尿道周围松解,尿道延伸,横行包皮内板岛状瓣部分尿道再造进行矫治,术中人工勃起实验及术后随访(3~78个月,平均34个月)观察下弯矫直的效果。结果:8例包皮脱套尿道松解患者,1例下弯矫治不全,1例术后1年复发。矫治不全者行背侧折叠缝合后矫正;复发的行瘢痕松解后得到再次矫直,随访1年未见复发。2例尿道延伸加背侧折叠缝合,无复发;2例行尿道切断松解,包皮瓣部分尿道再造的无复发。无血肿,感染,尿瘘,伤口裂开,尿道狭窄,尿道憩室发生。结论:应用腹侧技术(包皮脱套,尿道松解;尿道延伸;部分尿道重建)可以矫直先天性阴茎下弯,背侧技术(阴茎背侧白膜折叠缝合)可以不用或作为辅助手段用于修正小的弯曲改善形态,以减少阴茎长度的缩减。

[关键词]先天性阴茎下弯;尿道延伸术;尿道重建术;尿道松解术

[中图分类号]R699.8[文献标识码]A [文章编号]1008-6455(2009)02-0152-03

The study of the efficacy of ventral manipulation for correction of congenital

chordee without hypospadias

CHEN Bin, LI Yang-qun, LI Qiang, HUANG Xun-lei, DUAN Chen-wang, LI Sen-kai

(the Second Plastic Surgery Department, Plastic Surgery Hospital,Chinese Academy of Medical Science & Peking Union Medical College, Beijing 100144, China)

Abstract:ObjectiveThe aim of this study was to retrospectively assess the efficacy of the ventral surgical techniques in chordee without hypospadias. MethodsBetween March 2000 and August 2008,12 patients, ranging in age from 3 to 27 (mean 6.5) years, had chordee without hypospadias and underwent penile shaft degloving (8 cases), extensive mobilization of the urethra and dorsal plication (2 cases), and reconstructed partial urethra using a tubularized island flap (2 cases). Follow-up ranged from 3 months to 8 years, mean 34 months.ResultsOf the 8 cases undergoing degloving and releasing, residual curvature was present in 1 subject, and 6 months later, complete correction achieved by a plication of tunica albuginea, another one recurred one year after, and were corrected with a redo operation of scar resected and tunica albuginea placation. Of the 2 cases undergoing extensive mobilization of the urethra and dorsal placation, there was no complication. The 2 cases undergoing urethroplasty were straightened and did not recur during the follow-up.ConclusionsThe curvature of congenital chordee without hypospadias could be corrected using ventral manipulations (degloving, division and mobilization of the urethra, and urethroplasty). The dorsal operation (tunica albuginea placation) could be used as an ancillary technique to correct some residual bending. To avoid the risk of penis shortening, the authors suggest more radical and accurate ventral operations for the treatment of this scarce deformity.

Key words: chordee without hypospadias; congenital penile curvature; urethra mobilization; urethroplasty

先天性阴茎下弯是一种罕见的生殖器畸形。给患者造成严重心理负担,影响性生活甚至造成不育。手术方法有多种,阴茎背侧白膜的折叠缝合[1]包皮脱套,尿道松解;尿道延伸[2-3];阴茎海绵体切开腹侧移植,部分尿道重建;阴茎腹侧劈裂阴茎海绵体旋转缝合[4];拆卸重组[5]等。背侧操作(阴茎背侧白膜的折叠缝合[1])可引起阴茎短缩,尤其是矫正严重下弯病例时[6-9]。能否不用或少用背侧技术而使阴茎得到完全矫直目前尚无统一认识,为此我们观察了12例不同程度先天性阴茎下弯的病人应用腹侧技术(包皮脱套,尿道周围松解;尿道延伸;部分尿道再造)的矫直效果。

1临床资料

回顾2000年3月到2008年8月收治的12例主要应用腹侧技术(包皮脱套,尿道松解;尿道延伸;部分尿道重建)矫直的的先天性阴茎下弯患者。年龄3~27岁,平均6.5岁。尿道开口位于阴茎头,均为下弯,勃起时明显。根据下弯程度,对8例小于30°的行包皮脱套尿道松解,2例30°~50°的行尿道延伸背侧白膜折叠,2例超过50°的病变段尿道切断,包皮岛状瓣重建部分尿道。人工勃起观察下弯矫直程度,术后电话或来院复诊随诊3个月到8年,平均34个月。

2手术方法

2.1阴茎脱套尿道松解,尿道延伸,包皮瓣部分尿道再造:阴茎头牵引,人工勃起检查下弯程度。自包皮内板冠状沟0.5cm处环形切开,达系带下,沿腹侧中线切开达阴囊缝,阴茎浅、深筋膜之间分离达根部。脱套达腹侧薄弱部位时,尿道留置尿管作标记,粘连周围0.25%利多卡因浸润,张力下分离。脱套后,切断阴茎阴囊交界处蹼状纵膈,尿道周围筋膜多部位切断,深达阴茎海绵体白膜层。人工勃起试验,观察矫直效果。矫直不全的游离尿道,尿道下阴茎海绵体腹侧白膜多部位部分横行切开,使海绵体组织部分膨出。仍存在轻度弯曲者,于曲度最大处的阴茎背侧中缝处用可吸收线折叠缝合一针修正。如弯曲明显则切断尿道,应用包皮瓣重建缺损尿道。设计浅筋膜瓣覆盖松解后的尿道。包皮设计Byars瓣,转向腹侧闭合创面。

2.2 术后处理:抗生素预防感染,3~7天恢复排尿。

3结果

8例脱套松解患者,1例矫直不全,术后6个月行背侧折叠缝合矫直。1例术后一年复发,包皮脱套瘢痕松解后矫治,随诊一年无复发。2例尿道延伸背侧折叠者完全矫直,无复发。2例严重下弯尿道短缺,包皮瓣重建部分尿道者无复发。无血肿、感染、伤口裂开、尿瘘、尿道狭窄、尿道憩室发生。

4讨论

这组先天性阴茎下弯的患者中,单纯(10例)或主要采取腹侧矫直技术(2例加用了背侧折叠缝合),得到彻底(12例中1例出现矫直不全)和持久(随诊34个月)地矫直。

先天性阴茎下弯的病因尚无定论,Mettauer[10]认为下弯是发育为筋膜和尿道海绵体的间叶组织缺陷,未能分化而形成纤维索条,牵制阴茎造成。近来认为是正常生长的背侧组织和发育停滞的腹侧组织,两者不成比例造成的[11]。病理表现为阴茎腹侧组织短缺,包括皮肤,深浅筋膜,阴茎海绵体腹侧白膜、尿道海绵体,尿道等[9,12]。在个体生长发育过程中腹侧组织不能正常生长,腹背侧比例失衡,随年龄的增长,阴茎的发育,畸形会更加明显[12]。Horton & Devine[13]将其分为三型:Ⅰ型 尿道壁菲薄缺乏海绵体;Ⅱ型 尿道海绵体正常,深浅筋膜异常;Ⅲ型 尿道海绵体、深筋膜正常,浅筋膜异常。Duckett[10]分为两型:1型 原发下弯尿道海绵体组织正常;2型 原发下弯,尿道发育不良。Donnahoo[14]发现除去海绵体缺陷尿道发育不良的病例后,2/3患者为腹侧皮肤、Dartos筋膜缺陷,28%为阴茎海绵体比例失衡,剩下7%存在先天的尿道短缺。我们这组病人,轻度下弯8例中7例尿道海绵体发育尚可,属于Horton & Devine Ⅱ,Ⅲ型,Duckett 1型,其余5例伴不同程度尿道海绵体发育不良,尿道短缩,阴茎海绵体腹侧发育不良,腹背侧比例失衡。

阴茎下弯的术式可归纳为腹侧技术,背侧技术和旋转技术,背侧操作通过折叠缝合或切除一块背侧白膜后缝合缩短背侧长度[1],腹侧技术是松解延长腹侧组织(包皮脱套,尿道松解;尿道延伸[2-3];阴茎海绵体切开腹侧移植;尿道重建),旋转技术是改变曲度的方向(阴茎海绵体腹侧劈裂旋转缝合[4];拆卸重组[5]),使腹背侧弯曲变为内外侧。背侧技术简单有效,用在不超过30°的下弯,1999年调查,全美儿科学会48%的医生选择应背侧白膜切除折叠缝合即Nisbit手术来矫正轻度下弯[15]。但过度应用这种方法可能引起阴茎长度丢失,矫直不彻底,复发等[6-9],尤其对于严重下弯。游离尿道到球部,成人可以延长5cm,儿童2~2.5cm,对脱套松解不能完全矫直的,松解弯曲段尿道结合背侧一针折叠缝合可矫直,松解球部尿道可使45°左右的下弯矫直。游离的尿道由阴茎头和球部供血,不会发生血运障碍[4-5]。超过50°的重度弯曲,尿道切断松解阴茎海绵体腹侧组织,阴茎腹侧缺损用游离或带蒂组织移植修补,缺损尿道可重建[16-17]。Hendren WH[18]用包皮脱套,尿道延伸,腹侧移植,部分尿道再造治疗33例先天性阴茎下弯,其中7例因吻合口狭窄,尿瘘,憩室,难以矫直的下弯再次手术,最终所有病例通过腹侧手术获得完全矫直。

Bhat A[19]依次用包皮脱套,尿道松解,球部松解延伸,背侧折叠,尿道重建,其中尿道松解延伸作为主要操作治疗25例先天性阴茎下弯,发现包皮脱套加尿道延伸可以矫直76%的病人,尿道延伸加用背侧折叠可矫直8%病例,只有16%的患者需要分离切断尿道达到矫直。平均随诊26个月无下弯复发,只1例尿瘘和尿道狭窄需手术处理。

我们这组病例,折叠缝合只用于在腹侧矫直完成后残余下弯的修正。多数病例通过腹侧松解,白膜多处部分切开,尿道延伸可完全矫直,不丢失长度。

阴茎下弯的矫治约有8%~10%的并发症,包括:矫直不全,复发,尿瘘,尿道狭窄[14,20]。和病变程度及矫治方法有关。本组病例有1例矫直不全,15°左右的下弯,是为了保证膜状尿道的安全没做彻底尿道分离延伸所致,背侧折叠一处得到矫治。另1例术后一年复发,腹侧皮肤瘢痕粘连引起,重新脱套,设计浅筋膜瓣覆盖松解后的创面,完全矫直,术后一年未再复发。

先天性阴茎下弯是一种罕见的外生殖器畸形,矫治手术有多种,腹侧操作可以减少阴茎长度丢失,并可以矫治绝大多数病例,应当优先考虑,背侧操作,作为辅助手段,在腹侧缺损得到充分矫正的基础上适当应用,不宜作为下弯矫治的主要手段。

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[收稿日期]2008-08-21[修回日期]2008-12-01

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