Zhou Qian,Zhang Weiping,Song Hongcheng,et al.Analysis of risk factors for urethral fistula of hypospadias repair with tubularized incised plate urethroplasty[J].Journal of Clinical Pediatric Surgery,2023,22(12):1139-1145.[doi:10.3760/cma.j.cn101785-202202009-009]
尿道板切开卷管尿道成形术治疗尿道下裂的近期疗效及术后尿道瘘相关危险因素分析
- Title:
- Analysis of risk factors for urethral fistula of hypospadias repair with tubularized incised plate urethroplasty
- Keywords:
- Hypospadias; Surgical Procedures; Operative; Treatment Outcome; Postoperative Complications; Risk Factors; Child
- 摘要:
- 目的 探讨尿道板切开卷管尿道成形术(tubularized incised plate,TIP)治疗尿道下裂的近期疗效及术后发生尿道瘘的危险因素。方法 回顾性分析2018年12月至2020年1月在首都医科大学附属北京儿童医院泌尿外科初次行TIP手术治疗的尿道下裂患儿临床资料,通过电子手术记录和电话随访收集患儿临床资料,总结近期疗效,并对影响尿道瘘发生的可能因素进行单因素分析,选取单因素分析结果中有统计学意义的变量进行多因素Logistic回归分析。结果 本研究共纳入126例尿道下裂患儿,124例获随访,2例失访,平均随访时间20.2个月。患儿中位年龄24个月。不同尿道开口位置人数占比分别为:前型58.1%(72/124),中间型29.8%(37/124),后型12.1%(15/124)。术前存在不同程度阴茎下弯人数占比分别为:轻度29.8%(37/124),中度54.8%(68/124),重度15.3%(19/124)。约59.5%(22/37)的轻度阴茎下弯和33.8%(23/68)的中度阴茎下弯病例仅采用阴茎皮肤脱套,重度阴茎下弯(19/19)病例均采用阴茎皮肤脱套和背侧白膜折叠的方法。手术后近期并发症发生率为26.6%,其中尿道狭窄10例(10/124,8.1%),尿道瘘23例(23/124,18.5%),阴茎体瘘17例(17/124,13.7%),阴茎头裂开6例(6/124,4.8%)。单因素分析发现,年龄、术前阴茎下弯程度、新尿道覆盖物与TIP手术后尿道瘘之间无显著关联性,阴茎头宽度小于14 mm、后型尿道下裂、皮肤脱套后阴茎下弯超过15°以及行背侧白膜折叠是TIP手术后尿道瘘的可疑危险因素(P＜0.05)。多因素分析显示,阴茎头宽度小于14 mm是TIP术后尿道瘘的独立危险因素(P＜0.05)。结论 TIP手术治疗前型和中间型尿道下裂效果满意,治疗后型尿道下裂尿道瘘的发生率高;阴茎头宽度越小,皮肤脱套后阴茎下弯程度更重的患儿尿道瘘发生率更高。阴茎头宽度小于14 mm是TIP手术后尿道瘘的独立危险因素;TIP手术中利用Buck筋膜覆盖者尿道瘘的发生率更低,但发生尿道狭窄的可能性更大。
- Abstract:
- Objective To evaluate the efficacy and risk factors of urethral fistula with tubularized incised plate urethroplasty (TIPU).Methods From December 2018 to January 2020,126 children with hypospadias undergoing primary TIPU were consecutively recruited.General demographics and intraoperative data were recorded.Electronic surgical records were reviewed and telephone follow-ups conducted,including types and occurrence time of complications.Univariate analysis was conducted for potential risk factors of urethral fistula.Variables with statistical significance were selected for Logistic multivariate analysis.Results During a mean follow-up period of 20.2 mouths,2 cases were lost.Median age was 24 months.The position of urethral opening accounted for 58.1% of anterior type,29.8% of intermediate type and 12.1% of posterior type respectively.The preoperative proportion of mild/moderate/severe penile curvature was 29.8%,54.8% and 15.3% respectively.Penile curvature was corrected by penile degloving and dorsal plication.And 59.5% of children with mild penile curvature and 33.8% of moderate penile curvature were corrected only by degloving while all cases of severe penile curvature managed by dorsal plication.The overall complication rate of TIP surgery was 26.6%,including urethral stricture (n=10,8.1%),urethral fistula (n=23,18.5%),penile fistula (n=17,13.7%) and penile head fissure (n=6,4.8%).In univariate analysis,age,surgeon experiences or new urethra coverage had no correlation with postoperative urethral fistula.Urethral fistula was significantly higher in smaller glans,posterior hypospadias,severer penile curvature after degloving and chordee requiring dorsal plication.In multivariate analysis,glans width<14 mm were independent risk factors for postoperative urethral fistula with TIP.Conclusions TIPU has a satisfactory efficacy for anterior/mediate hypospadias.The incidence of urethral fistula for posterior hypospadias is high with a poor efficacy.Children with smaller glans or severer penile curvature after degloving have a higher incidence of urethral fistula and glans width<14 mm are independent risk factors for postoperative urethral fistula after TIPU.As compared to covering foreskin vascular pedicle,TIP surgery using Buck’s fascia coverage has a lower incidence of urethral fistula.However,the incidence of urethral stricture is higher.The indications of TIP surgery should be strictly controlled for lowering the incidence of postoperative complications.
参考文献/References:
[1] 中华医学会小儿外科学分会泌尿学组.尿道下裂专家共识[J].中华小儿外科杂志,2018,39(12):883-888.DOI:10.3760/cma.j.issn.0253-3006.2018.12.002. Group of Urology,Branch of Pediatric Surgery,Chinese Medical Association:Expert Consensus on Managing Hypospadias[J].Chin J Pediatr Surg,2018,39(12):883-888.DOI:10.3760/cma.j.issn.0253-3006.2018.12.002.
[2] Snodgrass W,Bush NC.Re-operative urethroplasty after failed hypospadias repair:how prior surgery impacts risk for additional complications[J].J Pediatr Urol,2017,13(3):289.e1-289.e6.DOI:10.1016/j.jpurol.2016.11.012.
[3] Wilkinson DJ,Farrelly P,Kenny SE.Outcomes in distal hypospadias:a systematic review of the Mathieu and tubularized incised plate repairs[J].J Pediatr Urol,2012,8(3):307-312 DOI:10.1016/j.jpurol.2010.11.008.
[4] Stanasel I,Le HK,Bilgutay A,et al.Complications following staged hypospadias repair using transposed preputial skin flaps[J].J Urol,2015,194(2):512-516.DOI:10.1016/j.juro.2015.02.044.
[5] Snodgrass W,Bush N.TIP hypospadias repair:a pediatric urology indicator operation[J].J Pediatr Urol,2016,12(1):11-18.DOI:10.1016/j.jpurol.2015.08.016.
[6] Zu’bi F,Chua M,El Ghazzaoui A,et al.Competency in tubularized incised plate repair for distal hypospadias:cumulative sum learning curve analysis of a single surgeon experience[J].J Urol,2020,204(6):1326-1332.DOI:10.1097/JU.0000000000001231.
[7] Bush NC,Snodgrass W.Pre-incision urethral plate width does not impact short-term tubularized incised plate urethroplasty outcomes[J].J Pediatr Urol,2017,13(6):625.e1-625.e6.DOI:10.1016/j.jpurol.2017.05.020.
[8] 刘愉,覃道锐,王学军,等.初治尿道下裂TIP手术后并发症的相关因素分析:309例单中心研究[J].临床小儿外科杂志,2020,19(12):1094-1099.DOI:10.3969/j.issn.1671-6353.2020.12.007. Liu Y,Qin DR,Wang XJ,et al.Analysis of related factors of complications after tubularized incised plate for initial hypospadias:a single-center report of 309 cases[J].J Clin Ped Sur,2020,19(12):1094-1099.DOI:10.3969/j.issn.1671-6353.2020.12.007.
[9] 沈一丁,唐达星,吴德华,等.规范手术操作程序的尿道板纵切卷管尿道成形术治疗原发性尿道下裂[J].中华小儿外科杂志,2020,41(2):171-175.DOI:10.3760/cma.j.issn.0253-3006.2020.02.015. Shen YD,Tang DX,Wu DH,et al.Clinical application of standardized tubularized incised plate urethroplasty for pediatric hypospadias[J].Chin J Pediatr Surg,2020,41(2):171-175.DOI:10.3760/cma.j.issn.0253-3006.2020.02.015.
[10] Pfistermuller KLM,McArdle AJ,Cuckow PM.Meta-analysis of complication rates of the tubularized incised plate (TIP) repair[J].J Pediatr Urol,2015,11(2):54-59.DOI:10.1016/j.jpurol.2014.12.006.
[11] Snodgrass W,Bush N.Recurrent ventral curvature after proximal TIP hypospadias repair[J].J Pediatr Urol,2021,17(2):222.e1-222.e5.DOI:10.1016/j.jpurol.2020.11.030.
[12] 潮敏,张殷,蒋加斌,等.BUCK筋膜联合阴茎头两翼整体覆盖恢复尿道下裂阴茎解剖结构在尿道板纵切尿道卷管成形术中的应用效果[J].临床小儿外科杂志,2020,19(12):1088-1093,1112.DOI:10.3969/j.issn.1671-6353.2020.12.006. Chao M,Zhang Y,Jiang JB,et al.Application experiences of integral covering technique of Buck’s fascia plus glans wings during tubularized incised plate urethroplasty for restoring normal penile anatomy of hypospadias[J].J Clin Ped Sur,2020,19(12):1088-1093,1112.DOI:10.3969/j.issn.1671-6353.2020.12.006.
[13] Bush NC,DaJusta D,Snodgrass WT.Glans penis width in patients with hypospadias compared to healthy controls[J].J Pediatr Urol,2013,9(6 Pt B):1188-1191.DOI:10.1016/j.jpurol.2013.05.004.
[14] Bush NC,Villanueva C,Snodgrass W.Glans size is an independent risk factor for urethroplasty complications after hypospadias repair[J].J Pediatr Urol,2015,11(6):355.e1-355.e5.DOI:10.1016/j.jpurol.2015.05.029.
[15] 唐耘熳.尿道下裂术后尿道狭窄、阴茎头裂开及尿道憩室的认识及处理[J].临床小儿外科杂志,2017,16(3):212-214.DOI:10.3969/j.issn.1671-6353.2017.03.002. Tang YM.Understanding and measures of urethral stricture,glan rupture and urethral diverticula after hypospadias repair[J].J Clin Ped Sur,2017,16(3):212-214.DOI:10.3969/j.issn.1671-6353.2017.03.002.
[16] 刘伟,武翔宇,王晓庆,等.尿道板纵切卷管尿道成形术后阴茎头裂开的相关危险因素分析[J].中华小儿外科杂志,2019,40(11):963-966.DOI:10.3760/cma.j.issn.0253-3006.2019.11.002. Liu W,Wu XY,Wang XQ,et al.Risk factors of glan dehiscence after repairing hypospadias with tubularized incised plate urethroplasty[J].Chin J Pediatr Surg,2019,40(11):963-966.DOI:10.3760/cma.j.issn.0253-3006.2019.11.002.
[17] Kaya C,Radmayr C.The role of pre-operative androgen stimulation in hypospadias surgery[J].Transl Androl Urol,2014,3(4):340-346.DOI:10.3978/j.issn.2223-4683.2014.12.01.
[18] Merriman LS,Arlen AM,Broecker BH,et al.The GMS hypospadias score:assessment of inter-observer reliability and correlation with post-operative complications[J].J Pediatr Urol,2013,9(6 Pt A):707-712.DOI:10.1016/j.jpurol.2013.04.006.
[19] Holland AJA,Smith GHH.Effect of the depth and width of the urethral plate on tubularized incised plate urethroplasty[J].J Urol,2000,164(2):489-491.DOI:10.1016/S0022-5347(05)67408-3.
[20] Sarhan O,Saad M,Helmy T,et al.Effect of suturing technique and urethral plate characteristics on complication rate following hypospadias repair:a prospective randomized study[J].J Urol,2009,182(2):682-686.DOI:10.1016/j.juro.2009.04.034.
[21] Weber DM,Sch?nbucher VB,Landolt MA,et al.The pediatric penile perception score:an instrument for patient self-assessment and surgeon evaluation after hypospadias repair[J].J Urol,2008,180(3):1080-1084.DOI:10.1016/j.juro.2008.05.060.
[22] Mosharafa AA,Agbo-Panzo D,Priso R,et al.Repair of hypospadias:the effect of urethral plate configuration on the outcome of Duplay-Snodgrass repair[J].Prog Urol,2009,19(7):507-510.DOI:10.1016/j.purol.2009.02.013.
[23] Ru W,Shen J,Tang DX,et al.Width proportion of the urethral plate to the glans can serve as an appraisal index of the urethral plate in hypospadias repair[J].Int J Urol,2018,25(7):649-653.DOI:10.1111/iju.13585.
[24] Section on Urology.Timing of elective surgery on the genitalia of male children with particular reference to the risks,benefits,and psychological effects of surgery and anesthesia[J].Pediatrics,1996,97(4):590-594.DOI:10.1542/peds.97.4.590.
[25] Lu WL,Tao YH,Wisniewski AB,et al.Different outcomes of hypospadias surgery between North America,Europe and China:is patient age a factor?[J].Nephrourol Mon,2012,4(4):609-612.DOI:10.5812/numonthly.1853.
[26] Ziada A,Hamza A,Abdel-Rassoul M,et al.Outcomes of hypospadias repair in older children:a prospective study[J].J Urol,2011,185(6 Suppl):2483-2485.DOI:10.1016/j.juro.2011.01.032.
[27] Eassa W,Jednak R,Capolicchio JP,et al.Risk factors for re-operation following tubularized incised plate urethroplasty:a comprehensive analysis[J].Urology,2011,77(3):716-720.DOI:10.1016/j.urology.2010.07.467.
[28] Yildiz T,Tahtali IN,Ates DC,et al.Age of patient is a risk factor for urethrocutaneous fistula in hypospadias surgery[J].J Pediatr Urol,2013,9(6 Pt A):900-903.DOI:10.1016/j.jpurol.2012.12.007.
[29] Bush NC,Holzer M,Zhang S,et al.Age does not impact risk for urethroplasty complications after tubularized incised plate repair of hypospadias in prepubertal boys[J].J Pediatr Urol,2013,9(3):252-256.DOI:10.1016/j.jpurol.2012.03.014.
[30] Snodgrass W,Villanueva C,Bush N.Primary and reoperative hypospadias repair in adults-are results different than in children?[J].J Urol,2014,192(6):1730-1733.DOI:10.1016/j.juro.2014.07.012.
相似文献/References:
[1]杜朝峻,丁力,胡英超,等.手术治疗婴幼儿法洛四联症83例[J].临床小儿外科杂志,2010,9(06):413.
DU Chao jun,DING Li,HU Ying chao,et al.Surgical treatment of Tetralogy of Fallot in infancy: Experiences of 83 cases.[J].Journal of Clinical Pediatric Surgery,2010,9(12):413.
[2]李勇,尹强,周小渔,等.术中胆道造影在先天性胆总管囊肿手术中的应用[J].临床小儿外科杂志,2010,9(06):430.
LI Yong,YIN Qiang,ZHOU Xiao yu,et al.The clinic application experience on intraoperative cholangiography in pediatric surgery.[J].Journal of Clinical Pediatric Surgery,2010,9(12):430.
[3]许芝林,王强,李琰,等.乙状结肠冗长症的术式选择探讨[J].临床小儿外科杂志,2010,9(06):432.
XU Zhi lin,WANG Qiang,LI Yan,et al.Initiatory exploration of the standard of surgical treatment methods for Dolichosigmoid.[J].Journal of Clinical Pediatric Surgery,2010,9(12):432.
[4]常绘文,沈振亚.右腋下小切口在儿童心内手术中的应用[J].临床小儿外科杂志,2010,9(06):439.
[5]罗洪,孙德霞,强红家,等.不同部位皮肤再造尿道的病理学研究[J].临床小儿外科杂志,2010,9(06):443.
[6]胡明,施诚仁,严志龙.脐环小切口治疗婴幼儿腹盆腔疾病的探讨[J].临床小儿外科杂志,2010,9(06):471.
[7]江峰赵阳孙莲萍金惠明马杰.婴幼儿阻塞性脑积水两种手术方式的疗效比较[J].临床小儿外科杂志,2011,10(01):0.
JIANG Feng,ZHAO Yang,SUN Liang ping,et al.Endoscopic third ventricul ostomy versus ventricul operitoneal shunt:clinical study of obstructive hydro cephalus in infants.[J].Journal of Clinical Pediatric Surgery,2011,10(12):0.
[8]王伟程少文彭磊林忠勤张伟陈庆玉寇冬权.弹性髓内钉在儿童肱骨骨折中的应用[J].临床小儿外科杂志,2011,10(01):0.
WANG Wei,CHENG Shaowen,PENG Lei,et al.Application of elastic intramedullary nailing in pediatric humeral fractures.[J].Journal of Clinical Pediatric Surgery,2011,10(12):0.
[9]陈快 黄金狮 戴康临 陶俊峰 赖勇强 陶强. 腹腔镜与开腹Ladd手术治疗新生儿肠旋转不良效果比较[J].临床小儿外科杂志,2011,10(02):128.
[J].Journal of Clinical Pediatric Surgery,2011,10(12):128.
[10]郑里乐 许慧萍 彭牡丹. 产时子宫外胎儿手术的护理配合[J].临床小儿外科杂志,2011,10(02):157.
[J].Journal of Clinical Pediatric Surgery,2011,10(12):157.
[11]丁勇,魏华,孔燕,等.横裁包皮岛状皮瓣法在尿道下裂治疗中的应用[J].临床小儿外科杂志,2010,9(06):474.
[12]景登攀张根领孙蔓丽.改良Snodgrass术治疗尿道下裂疗效观察[J].临床小儿外科杂志,2011,10(01):0.
[13]白明 张敬悌 葛文安 王盛兴 郭涛 张岗 杨增雷. 医用透明硅胶膜在尿道下裂手术伤口包扎中的应用[J].临床小儿外科杂志,2012,11(02):91.
[14]刘波 陈太忠 李光亮 舒中甫 石代红 杨英.改良尿道板纵切卷管尿道成型术治疗儿童尿道下裂６例[J].临床小儿外科杂志,2013,12(01):72.
[15]贾幸,谢华.尿道下裂阴茎下弯的组织学和手术治疗研究进展[J].临床小儿外科杂志,2019,18(09):795.[doi:10.3969/j.issn.1671-6353.2019.09.018]
Jia Xing,Xie Hua.Research advances in histology and surgery of ventral penile curvature in hypospadias[J].Journal of Clinical Pediatric Surgery,2019,18(12):795.[doi:10.3969/j.issn.1671-6353.2019.09.018]
[16]郭慧杰,孙雪蕊,李守林,等.儿童尿道下裂TIP手术后近期尿流率变化研究[J].临床小儿外科杂志,2023,22(02):129.[doi:10.3760/cma.j.cn101785-202211059-006]
Guo Huijie,Sun Xuerui,Li Shoulin,et al.Variation tendency of urinary flow after tubularized incised plate urethroplasty in children with hypospadias[J].Journal of Clinical Pediatric Surgery,2023,22(12):129.[doi:10.3760/cma.j.cn101785-202211059-006]
[17]杨珍珍,李佳义,刘沛,等.一期Duckett与分期Bracka尿道成形术治疗非远端型尿道下裂术后并发症的Meta分析[J].临床小儿外科杂志,2023,22(02):168.[doi:10.3760/cma.j.cn101785-202202018-014]
Yang Zhenzhen,Li Jiayi,Liu Pei,et al.Efficacy of one-stage Duckett versus staged Bracka urethroplasty for nondistal hypospadias: a meta-analysis[J].Journal of Clinical Pediatric Surgery,2023,22(12):168.[doi:10.3760/cma.j.cn101785-202202018-014]
[18]王登辉,崔梦杰,韩晓江,等.性别发育异常合并近端尿道下裂尿道成形术后并发症的危险因素分析[J].临床小儿外科杂志,2023,22(09):849.[doi:10.3760/cma.j.cn101785-202211056-010]
Wang Denghui,Cui Mengjie,Han Xiaojiang,et al.Risk factors of complications after urethroplasty in children with gender dysplasia and proximal hypospadias[J].Journal of Clinical Pediatric Surgery,2023,22(12):849.[doi:10.3760/cma.j.cn101785-202211056-010]
备注/Memo
收稿日期:2022-2-7。
基金项目:国家重点研发项目(2016YFC1000800)
通讯作者:张潍平,Email:zhangwp59616406@126.com