阴茎远端尿道狭窄疾病的手术治疗方式

doi:10.19723/j.issn.1671-167X.2024.06.021

摘要/Abstract

摘要：

目的: 探讨阴茎远端尿道狭窄疾病的手术治疗方式。方法: 回顾性收集自2018年1月至2022年12月就诊于首都医科大学附属北京积水潭医院的80例阴茎远端尿道狭窄患者的临床资料，包括男性生殖器苔藓样硬化(male genital lichen sclerosus, MGLS) 33例，医源性损伤25例，尿道下裂术后12例，外伤等其他原因10例。狭窄仅累及尿道外口54例，其中38例行尿道外口切开术(meatotomy, MO)，7例行阴茎皮瓣尿道成形术(penile skin flap urethroplasty, PSFU), 9例行口腔黏膜尿道成形术(oral mucosa graft urethroplasty, OMGU)；狭窄同时累及尿道外口和舟状窝26例，其中1例行PSFU，25例行OMGU。以术式不同将80例患者分为MO、PSFU、OMGU 3组，平均年龄分别为(48.8±20.0) 岁、(53.3±21.8) 岁、(44.5±16.4) 岁；平均体重指数(body mass index, BMI) 分别为(28.6±3.9) kg/m²、(29.6±3.2) kg/m²、(29.2±4.8) kg/m²；平均术前最大尿流率分别为(5.8±2.3) mL/s、(6.8±2.4) mL/s、(5.7±3.1) mL/s。结果: 所有手术均顺利完成，围术期无Clavien Ⅲ或Ⅳ级并发症发生。3组中位狭窄长度(术中测量)分别为1.1 (1.0, 1.6)、1.5 (1.1, 2.0)、4.0 (2.5, 5.0) cm；中位手术时间分别为60.0 (60.0, 75.0)、85.0 (75.0, 112.5)、180.0 (75.0, 330.0) min；中位估计出血量分别为5.0 (2.0, 10.0)、15.0 (5.0, 42.5)、180.0 (135.0, 216.3) mL；术后中位住院日分别为3.5 (2.0, 5.0)、6.5 (3.5, 7.0)、7.5 (7.0, 11.3) d；术后中位随访时间分别为40.0 (26.3, 57.3)、55.0 (18.8, 62.8)、52.5 (30.5, 64.0) 个月；术后中位最大尿流率分别为18.3 (15.5, 19.8)、19.2 (16.1, 20.1)、17.2 (14.2, 19.6) mL/s。38例MO中33例排尿通畅，无需干预；5例狭窄复发，需定期尿道扩张。8例PSFU中7例排尿通畅，无需干预；1例出现尿瘘，建议干预，但患者决定维持现状。34例OMGU中28例排尿通畅，无需干预；6例狭窄复发，其中5例需定期尿道扩张，1例再行重建手术。所有病例术后成功率为85.0%，再干预率为15.0%。统计分析发现，3组患者的狭窄病因(P=0.002)、狭窄部位(P < 0.001)、狭窄长度(P < 0.001)、手术时间(P < 0.001)、估计出血量(P < 0.001) 及术后住院日(P < 0.001)差异有统计学意义；年龄、BMI、既往尿道狭窄手术史、术前最大尿流率、随访时间、术后最大尿流率及再干预率均差异无统计学意义。单因素及多因素Logistic回归分析发现，既往尿道狭窄手术史是术后再干预的危险因素(P=0.026)。结论: MO和PSFU主要适用于短段(≤1.5 cm) 阴茎远端尿道狭窄，OMGU则适用于处理更长段狭窄；MO和OMGU可用于MGLS病例；PSFU和OMGU更有利于改善尿道外口外观；阴茎远端尿道狭窄手术治疗的成功率为85.0%，15.0%的患者术后仍需外科干预，既往尿道狭窄手术史是术后再干预的危险因素。

关键词: 尿道外口, 舟状窝, 阴茎皮瓣, 口腔黏膜, 尿道成形术

Abstract:

Objective: To evaluate the surgical methods for treating distal urethral stricture. Methods: The clinical data of 80 patients with distal urethral stricture in Beijing Jishuitan Hospital, Captial Medical University between January 2018 and December 2022 were retrospectively collected. Including male genital lichen sclerosus (MGLS) 33 cases, iatrogenic injury 25 cases, postoperative hypospadias 12 cases, and other causes such as trauma 10 cases. Among these cases, strictures involved the urethral meatus in 54 instances, of which 38 were treated with meatotomy (MO), 7 with penile skin flap urethroplasty (PSFU), and 9 with oral mucosa graft urethroplasty (OMGU). There were also 26 instances where strictures involved both the navicular fossa and meatus; one case underwent PSFU while 25 underwent OMGU. Based on different surgical methods used for treatment purposes we divided the patients into MO group, PSFU group and OMGU group. The age of the three groups was (48.8±20.0) years, (53.3±21.8) years and (44.5±16.4) years. The mean±SD body mass index (BMI) was (28.6±3.9) kg/m², (29.6±3.2) kg/m² and (29.2±4.8) kg/m². The preoperative maximum flow rate was (5.8±2.3) mL/s, (6.8±2.4) mL/s and (5.7±3.1) mL/s. Results: All the operations were successfully completed without Clavien Ⅲ or Ⅳ complications. The median length of strictures (measured intraoperatively) in the three groups were 1.1 (1.0, 1.6), 1.5 (1.1, 2.0) and 4.0 (2.5, 5.0) cm. The median operation time was 60.0 (60.0, 75.0), 85.0 (75.0, 112.5) and 180.0 (75.0, 330.0) min. The median estimated blood loss was 5.0 (2.0, 10.0), 15.0 (5.0, 42.5) and 180.0 (135.0, 216.3) mL. The median postoperative hospital stay was 3.5 (2.0, 5.0), 6.5 (3.5, 7.0) and 7.5 (7.0, 11.3) days. The median follow-up duration was 40.0 (26.3, 57.3), 55.0 (18.8, 62.8) and 52.5 (30.5, 64.0) months. The median postoperative maximum flow rate was 18.3 (15.5, 19.8), 19.2 (16.1, 20.1) and 17.2 (14.2, 19.6) mL/s. Among the 38 patients with MO, 33 cases had normal urination without reintervention, and 5 cases experienced recurrent strictures and required regular urethral dilation. Among the 8 patients with PSFU, 7 cases had normal urination without reintervention, and one case developed a urinary fistula, for which intervention was recommended but the patient opted to maintain the status quo. Among the 34 patients with OMGU, 28 cases had normal urination without reintervention. There were 6 instances of stenosis recurrence, with 5 cases requiring regular urethral dilations and one case requiring reconstructive surgery. The overall success rate of operation was 85.0%, and the reintervention rate was 15.0%. Statistical analysis revealed significant differences in etiologies among the three groups (P=0.002), as well as in stricture locations (P < 0.001), length of strictures (P < 0.001), operation time (P < 0.001), estimated blood loss (P < 0.001) and postoperative hospital stays (P < 0.001). However, no significant differences were observed in terms of age, BMI, history of previous urethral stricture surgeries, preoperative maximum flow rate, follow-up duration, postoperative maximum flow rate and reintervention rate. Univariate and multivariate Logistic regression analyses indicated that a history of previous urethral stricture surgeries was a risk factor for postoperative reintervention (P=0.026). Conclusion: MO and PSFU are primarily suitable for treating short-segment (≤1.5 cm) distal penile urethral strictures, whereas OMGU is more appropriate for longer segment strictures. MO and OMGU can both be utilized in managing MGLS cases. PSFU and OMGU are more conducive to improving the appearance of the urethral meatus. The success rate of surgical management of distal penile urethral stricture is 85.0%, 15.0% of the patients still require surgical intervention after surgery, and having history of previous urethral stricture surgeries is a risk factor for postoperative reintervention.

Key words: Urethral meatus, Navicular fossa, Penile skin flap, Oral mucosa, Urethroplasty

中图分类号:

R697.1

王杰, 王建伟, 夏海缀, 徐啸, 翟建坡, 何峰, 黄广林, 李贵忠. 阴茎远端尿道狭窄疾病的手术治疗方式[J]. 北京大学学报（医学版）, 2024, 56(6): 1075-1082.

Jie WANG, Jianwei WANG, Haizhui XIA, Xiao XU, Jianpo ZHAI, Feng HE, Guanglin HUANG, Guizhong LI. Surgical management of the distal urethral stricture diseases[J]. Journal of Peking University (Health Sciences), 2024, 56(6): 1075-1082.

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参考文献 16

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Items	MO (n=38)	PSFU (n=8)	OMGU (n=34)	P value
Age/years, $\bar x \pm s$	48.8±20.0	53.3±21.8	44.5±16.4	0.410
BMI/(kg/m²), $\bar x \pm s$	28.6±3.9	29.6±3.2	29.2±4.8	0.751
Etiology, n (%)				0.002^*
MGLS	18 (47.4)	0 (0)	15 (44.1)
Iatrogenic	15 (39.5)	4 (50.0)	6 (17.7)
Hypospadias	1 (2.6)	1 (12.5)	10 (29.4)
Others	4 (10.5)	3 (37.5)	3 (8.8)
Stricture locations, n (%)				< 0.001^*
Pure meatus	38 (100)	7 (87.5)	9 (26.5)
Navicular fossa and meatus	0 (0)	1 (12.5)	25 (73.5)
History of previous urethral stricture surgeries^a, n (%)				0.098
Yes	16 (42.1)	2 (25.0)	21 (61.8)
No	22 (57.9)	6 (75.0)	13 (38.2)
Preoperative cystostomy, n (%)				0.249
Yes	8 (21.1)	3 (37.5)	13 (38.2)
No	30 (78.9)	5 (62.5)	21 (61.8)
Preoperative urine culture, n (%)				0.935
Positive	10 (26.3)	2 (25.0)	10 (29.4)
Negative	28 (73.7)	6 (75.0)	24 (70.6)
Hypertension, n (%)				0.808
Yes	11 (28.9)	2 (25.0)	7 (20.6)
No	27 (71.1)	6 (75.0)	27 (79.4)
Diabetes, n (%)				0.215
Yes	14 (36.8)	5 (62.5)	10 (29.4)
No	24 (63.2)	3 (37.5)	24 (70.6)
Preoperative Qmax/(mL/s), $\bar x \pm s$	5.8±2.3	6.8±2.4	5.7±3.1	0.544
Stricture length/cm, M (P₂₅, P₇₅)	1.1 (1.0, 1.6)	1.5 (1.1, 2.0)	4.0 (2.5, 5.0)	< 0.001^*
Operation time/min, M (P₂₅, P₇₅)	60.0 (60.0, 75.0)	85.0 (75.0, 112.5)	180.0 (75.0, 330.0)	< 0.001^*
Estimated blood loss/mL, M (P₂₅, P₇₅)	5.0 (2.0, 10.0)	15.0 (5.0, 42.5)	180.0 (135.0, 216.3)	< 0.001^*
Postoperative hospital stay/d, M (P₂₅, P₇₅)	3.5 (2.0, 5.0)	6.5 (3.5, 7.0)	7.5 (7.0, 11.3)	< 0.001^*
Follow-up duration/months, M (P₂₅, P₇₅)	40.0 (26.3, 57.3)	55.0 (18.8, 62.8)	52.5 (30.5, 64.0)	0.443
Postoperative Qmax/(mL/s), M (P₂₅, P₇₅)	18.3 (15.5, 19.8)	19.2 (16.1, 20.1)	17.2 (14.2, 19.6)	0.064
Reintervention, n (%)	5 (13.2)	1 (12.5)	6 (17.6)	0.898

Items	Univariate analysis		Multivariate analysis
Items	OR (95%CI)	P value	OR (95%CI)	P value
Age/years	0.976 (0.942, 1.010)	0.167
BMI/(kg/m²)	0.967 (0.811, 1.153)	0.712
Etiology
MGLS	1	0.578
Iatrogenic	0.487 (0.086, 2.747)	0.415
Hypospadias	1.867 (0.371, 9.399)	0.449
Others	1.400 (0.227, 8.626)	0.717
Stricture locations	1.599 (0.455, 5.623)	0.465
History of previous urethral stricture surgeries^a	15.714 (1.918, 128.751)	0.010^*	13.943 (1.365, 142.394)	0.026^**
Preoperative cystostomy	1.200 (0.324, 4.442)	0.785
Preoperative urine culture	0.863 (0.210, 3.521)	0.833
Hypertension	1.000 (0.242, 4.126)	1.000
Diabetes	4.476 (1.213, 16.521)	0.024^*	3.840 (0.882, 16.708)	0.073
Preoperative Qmax/(mL/s)	1.176 (0.922, 1.500)	0.191
Length of strictures/cm	1.241 (0.824, 1.869)	0.302
Operation time/min	1.008 (1.000, 1.017)	0.059^*	0.999 (0.985, 1.014)	0.945
Estimated blood loss/mL	1.013 (1.000, 1.026)	0.046^*	1.011 (0.991, 1.030)	0.287
Postoperative hospital stay/d	1.220 (1.030, 1.446)	0.022^*	1.090 (0.839, 1.416)	0.519
Follow-up duration/months	1.012 (0.979, 1.047)	0.471
Postoperative Qmax/(mL/s)	0.753 (0.624, 0.908)	0.003^*

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