目的 探讨改良近端尿道断离法治疗后尿道狭窄的效果.方法 回顾性分析2013年1月至2023年5月上海市第六人民医院收治的1 787例骨盆骨折伴后尿道断裂或闭锁患者的临床资料.患者均为男性,年龄18个月至76岁,平均年龄(34.3±4.1)岁.车祸致骨盆挤压伤867例,高空坠落致骨盆损伤464例,车床致骨盆挤压伤456例.术前行耻骨上膀胱造瘘1 536例.所有患者术前均行排泄性和逆行尿道造影,187例行尿道超声检查,1 440例行尿道镜检查,38例行尿道MRI检查.狭窄或闭锁段长度(3.1±0.5)cm.后尿道狭窄(尿道连续性尚存)281例(15.7％);后尿道完全闭锁1 506例(84.3％).术前行尿道膀胱软镜和MRI检查了解精阜至狭窄或闭锁段距离,＞2 cm 1 434例(80.2％),≤2 cm 353例(19.8％).术前国际勃起功能指数(IIEF-5)评分≤21分1 073例,≥22分672例,42例无性活动拒绝问卷调查.手术方法:会阴区域消毒,用尿道探子自膀胱造瘘口置入,经膀胱颈口达闭锁尿道近端,用左手示指触及探子顶端于会阴处体表的冲击点并标记.以此点为中心,做倒"Y"形切口,切开皮肤、皮下组织,分离球海绵体肌,显露球部尿道.分离球部尿道并用牵引带拉出,在球部尿道上方显露瘢痕结缔组织并切开,显露会阴横韧带.在探子指引下,于尿道上方用电刀切断会阴横韧带,下方沿会阴中心腱水平方向将尿道与直肠前壁分离,两侧切断尿道周围瘢痕组织,达近端尿道探子顶端.切开探子顶端瘢痕组织后显露探子,用组织剪去除近端尿道周围瘢痕并修剪后备用.远端尿道向上方游离至足够长度后,剪除瘢痕组织,稍作修剪后备用.用4-0可吸收线分别于尿道1、2、4、5、7、8、10、11点位缝合8针,留置F16导尿管后关闭切口.术后4周拔除导尿管嘱患者自行排尿,6个月后行尿流率检查和IIEF-5评分,最大尿流率(Qmax)＞15ml/s定义为手术成功,IIEF-5评分≥22分定义为勃起功能正常.结果 本研究1 787例手术均顺利完成,手术时间(75.5±8.5)min,术中出血量(110.4±13.2)ml.62例术中输血,输血量(285.5±15.5)ml.术后随访(26.1±4.5)个月,1 729例(96.7％)Qmax＞15ml/s;38例术后排尿不畅,其中26例行尿道内切开术后好转,12例3个月后再次行耻骨下缘切除尿道吻合术;20例术后并发尿失禁,其中11例行尿道悬吊术后好转,5例安装人工尿道括约肌后达到社会控尿,余4例不愿接受手术治疗,随访观察.1 202例(67.2％)IIEF-5评分≤21分,其中528例予西地那非治疗,120例有不同程度好转;15例安装可膨胀性阴茎支撑体恢复勃起功能.结论 经会阴途径改良近端尿道断离法适用于大部分后尿道狭窄手术,能快速准确地找到近端尿道,有助于简化尿道吻合的手术步骤,临床疗效确切.
Effect of the improved proximal urethral transection in the treatement of posterior urethral stricture
Objective To investigate the therapeutic efficacy of the improved proximal urethral transection method in treating posterior urethral stricture.Methods A retrospective analysis was conducted on clinical data from 1 787 male patients treated from January 2013 to May 2023 for pelvic fractures associated with posterior urethral disruption or obliteration.The ages of the patients ranged from 18 months to 76 years,with an average age of(34.3±4.1)years.Etiologies included pelvic compression injuries due to traffic accidents(867 cases),falls from height(464 cases),and machine-related pelvic compression injuries(456 cases).Preoperative suprapubic cystostomy was performed in 1 536 cases.All patients underwent preoperative excretory and retrograde urethrography,urethral ultrasonography in 187 cases,urethroscopy in 1440 cases,and urethral MRI in 38 cases.The average length of the stricture or obliterated segment was(3.1±0.5)cm.Posterior urethral stricture was present in 281 cases(15.7％)with maintained urethral continuity,while complete posterior urethral obliteration occurred in 1 506 cases(84.3％).Preoperative urethrocystoscopy and urethral MRI were used to determine the distance from the verumontanum to the stricture or obliterated segment,＞2 cm identified in 1 434 cases(80.2％)and ≤2 cm in 353 cases(19.8％).Before surgery,1 073 cases had IIEF-5 scores ≤21 points,672 cases had IIEF-5 scores ≥22 points,and 42 cases without sexual activity refused the questionnaire survey.Surgical method:The perineal region was disinfected,and a urethral probe was introduced through the suprapubic cystostomy site into the bladder neck,directly reaching the proximal end of the obliterated urethra.The tip of the probe was palpated with the left index finger on the body surface and marked.An inverted"Y"-shaped incision was made centered around this point,followed by dissection of the skin,subcutaneous tissue,and bulbospongiosus muscle to expose the bulbous urethra.The bulbous urethra was isolated and retracted.Scar tissue above the bulbous urethra was incised to expose the perineal transverse ligament.Guided by the probe,the perineal transverse ligament was transected using an electrosurgical knife above the urethra,while horizontal dissection was performed along the perineal central tendon to separate the urethra from the anterior rectal wall.Bilateral dissection of the surrounding scar tissues extended up to the tip of the probe at the posterior urethra.Scar tissue at the probe tip was incised,revealing the probe.Then,proximal urethra was prepared and set aside after its around scar tissue was trimmed.The distal urethra was mobilized to an adequate length upwards,with scar tissue trimmed and prepared as well.Using 4-0 absorbable sutures,eight sutures were placed at positions 1,2,4,5,7,8,10,and 11 on the urethra.An F16 urethral catheter was left in place,and the incision was closed.Record the duration of surgery,amount of bleeding,number of blood transfusions,and transfusion volume.Four weeks postoperatively,the catheter was removed,and patients were instructed to urinate spontaneously.Six months later,assessments included uroflowmetry and the international index of erectile function(IIEF-5)questionnaire,with a Qmax＞15 ml/s indicating successful surgery and an IIEF-5 score ≥ 22 indicating normal erectile function.Results All patients successfully completed the surgery,the average operation time was(75.5±8.5)minutes,and the average intraoperative blood loss was(110.4±13.2)ml.62 patients received intraoperative blood transfusion,with an average volume of(285.5±15.5)ml.The follow-up period was(26.1±4.5)months.A total of 1 729 patients(96.7％)achieved a Qmax＞15 ml/s.Among the 38 patients with postoperative voiding difficulties,26 patients improved after internal urethrotomy,and 12 patients underwent a subpubic anastomosis three months later.Postoperative urinary incontinence occurred in 20 patients:11 patients improved after urethral suspension surgery,and 5 patients achieved urinary control with an artificial urinary sphincter.The remaining patients were under follow-up(unwilling to undergo surgery).Erectile dysfunction(IIEF-5 score≤21)was observed in 1 202 cases(67.2％),with 528 treated with sildenafil,resulting in varying degrees of improvement in 120 cases.Fifteen patients restored erectile function with expandable penile prostheses.Conclusions The perineal approach for the improved proximal urethral transection is suitable for most posterior urethral stricture surgeries.It enables rapid and accurate identification of the proximal urethra,simplifies the steps of urethral anastomosis,and demonstrates clinical efficacy.
Urethral obliterationUrological surgeryPerineal approachRepair and reconstruction
NETL
NSTL
万方数据
