基于尿道下裂手术皮瓣转移思路矫治隐匿阴茎的效果分析

基于尿道下裂手术皮瓣转移思路矫治隐匿阴茎的效果分析

蔡永川1 黄朝友1 王炜1 唐耘熳2 刘愉1 朱志全1 王学军2

本文来源：《中华整形外科杂志》2023年6月第39卷第6期

DOI:10. 3760 / cma.j.cn114453-20220920-00288

作者单位：1成都市第二人民医院泌尿外科，成都610000；2电子科技大学附属医院四川省人民医院儿童医学中心小儿外科，成都610072

通信作者：王学军，Email: wangxuejun028@sina.com

引用本文

蔡永川, 黄朝友, 王炜, 等. 基于尿道下裂手术皮瓣转移思路矫治隐匿阴茎的效果分析 [J] . 中华整形外科杂志, 2023, 39(6) : 614-620. DOI: 10.3760/cma.j.cn114453-20220920-00288.

【摘要】

目的探讨基于尿道下裂手术皮瓣转移思路矫治隐匿阴茎的临床应用效果。

方法回顾性分析2017年7月至2021年7月成都市第二人民医院泌尿外科和四川省人民医院儿童医学中心小儿外科收治的隐匿阴茎患儿的临床资料。对照组采用传统手术方式，试验组采用基于尿道下裂手术皮瓣转移思路的改良手术方式。统计分析2组术后皮瓣缺血、水肿、皮肤裂开等近期并发症情况，以及术后6个月阴茎外观的Boemers评级(良好、一般、不良)、温哥华瘢痕量表(VSS)评估的瘢痕增生情况(轻度、中度、重度)及阴茎整体外形情况(塔形、圆柱形、倒塔形)。计数资料采用卡方检验进行分析。

结果共纳入298例患儿，年龄2.5~13.7岁，平均6.4岁。对照组103例，试验组195例。所有入组患儿均一期顺利完成手术，术后3~4 d出院，平均恢复时间3~4周。术后随访时间均>6个月。对照组术后出现皮瓣缺血2例(1.9%)，皮肤裂开3例(2.9%)，试验组术后2例(1.0%)患儿出现皮肤裂开，2组的近期并发症发生率的差异无统计学意义[4.9%(5/103)vs. 1.0%(2/195), P>0.05]。试验组Boemers评级"良好"的比例高于对照组[93.3%(182/195)vs. 71.8%(74/103)，P<0.01]。试验组VSS评估的中重度瘢痕增生的比例小于对照组[6.2%(12/195)vs. 26.2%(27/103)，P<0.01]。试验组阴茎整体外形呈接近正常阴茎的圆柱形的比例明显高于对照组[81.5%(159/195)vs. 60.2%(62/103)，P<0.01]。

结论基于尿道下裂手术皮瓣转移思路矫治隐匿阴茎的改良术式与传统手术方式相比，更注重皮瓣的整体规划及筋膜层的张力分布，可更有效解决隐匿阴茎皮肤覆盖不足的问题，减少术后瘢痕形成，外生殖器外观自然且更接近正常，手术效果确切，术后远期并发症发生率低。

【关键词】阴茎疾病；隐匿阴茎；尿道下裂；皮瓣转移；张力分布

Curative effect analysis of treating concealed penis based on the idea of flap transfer in the treatment of hypospadias

Cai Yongchuan1, Huang Chaoyou1, Wang Wei1, Tang Yunman2, Liu Yu1, Zhu Zhiquan1, Wang Xuejun2

1Department of Urology, Chengdu Second People’s Hospital, Chengdu 610000, China; 2Department of Pediatric Surgery at Children’s Medical Center, Sichuan Provincial People’s Hospital, Affiliated Hospital of University of Electronic Science and Technology of China, Chengdu 610072, China

Corresponding author: Wang Xuejun, Email: wangxuejun028@sina.com

【Abstract】

Objective To investigate the clinical effect of surgical treatment of concealed penis based on the idea of flap transfer in the treatment of hypospadias.

Methods Retrospectively analyzed the clinical data of children with concealed penis admitted to the Urology Department of Chengdu Second People’s Hospital and Department of Pediatric Surgery at Children’s Medical Center of Sichuan Provincial People’s Hospital, from July 2017 to July 2021. The control group used the traditional surgical method and the experimental group used a modified surgical approach based on the idea of flap transfer in the treatment of hypospadias. Short-term complications such as flap ischemia, edema, and skin dehiscence were statistically analyzed in the two groups, as well as the Boemers rating of penile appearance (good, general, poor), Vancouver scar scale (VSS) (mild, moderate, severe), overall penis shape (tower, cylindrical, inverted tower) at 6 months after surgery. Count data were analyzed using the Chi-square test.

Results 298 children, aged 2.5 to 13.7 years, with a mean age of 6.4 years, were enrolled in the study. 103 children were in the control group, and 195 children were in the experimental group. All enrolled patients were operated successfully in the first stage and were discharged 3-4 days after the operation, with an average recovery time of 3-4 weeks. After a follow-up of more than 6 months, in the control group, 2 cases (1.9%) of flap ischemia and 3 cases (2.9%) of skin dehiscence occurred after surgery. Two children (1.0%) in the experimental group had skin dehiscence after surgery, and the difference in the recent complication rate between the two groups was not significant [4.9%(5/103) vs. 1.0%(2/195), P>0.05]. The proportion of Boemers rated"good"in the experimental group was higher than that in the control group [93.3% (182/195) vs. 71.8% (74/103), P<0.01]. The proportion of moderate to severe scarring assessed by VSS was lower in the experimental group than in the control group [6.2% (12/195) vs. 26.2% (27/103), P<0.01]. The proportion of the overall penis shape of the penis close to the cylindrical shape of the normal penis in the experimental group was significantly higher than that in the control group [81.5% (159/195) vs. 60.2% (62/103), P<0.01].

Conclusion Compared with the traditional surgical method, the modified surgical approach based on the idea of flap transfer in the treatment of hypospadias attaches more importance to the overall planning of the flap and the tension distribution of the fascial layer, which can be more effective to solve the problem of insufficient coverage of the concealed penile skin and reduce postoperative scar formation. Moreover, the appearance of the external genitalia is natural and closer to normal, the surgical effect is exact, and the long-term postoperative complications are lower.

【Key words】Penile diseases; Concealed penis; Hypospadias; Transfer of skin flap; Distribution of strain

Disclosure of Conflicts of Interest: The authors have no financial interest to declare in relation to the content of this article.

Ethical Approval: This study was conducted in accordance with the Helsinki Declaration.

隐匿阴茎是一种儿童常见的外生殖器发育异常，其病因主要是阴茎肉膜中的弹性纤维增厚，弹性差，阴茎筋膜发育不良以及附着异常限制阴茎显露，部分患儿阴茎肉膜与阴茎深筋膜间脂肪堆积进一步影响阴茎体的显露[1,2]。临床中等待观察和手术矫治是主要的处理方式，目前隐匿阴茎的手术方式包括Shriaki术、Johnston术、Devine术、Brisson术、Maizels术等，以及各种基础术式的改良手术方式，但各种术式仍存在手术效果争议及术后并发症等一系列问题[3]。尿道下裂手术是修复重建手术中最具挑战和难度的手术之一，在手术过程中，尤其强调对皮瓣的整体规划和皮下筋膜组织张力的重建。本研究团队在长期的临床诊治中，积累了较多尿道下裂手术皮瓣重新分布的经验，基于此，我们尝试采用尿道下裂手术皮瓣转移思路来矫治隐匿阴茎，以期达到更好的手术效果，现将相关结果进行总结。

资料与方法

一、资料选择

收集2017年7月至2021年7月成都市第二人民医院泌尿外科和四川省人民医院儿童医学中心小儿外科收治的隐匿阴茎患儿的临床资料，进行回顾性分析。患儿均因外生殖器发育异常就诊，门诊查体后诊断明确，收治入院。纳入标准：完全符合隐匿阴茎诊断标准，阴茎海绵体发育正常但显露较差，耻骨联合处无明显脂肪堆积，于耻骨联合上方推压阴茎皮肤可使阴茎体正常显露，松手后阴茎回缩至原状态。排除标准：(1)单纯性包茎、埋藏阴茎、蹼状阴茎、束缚阴茎、尿道下裂、小阴茎等其他类型的阴茎发育异常；(2)既往有相关外生殖器手术史。

本研究已充分取得患者和家属的知情同意，同意将相关资料用于本项研究；同时，本研究符合赫尔辛基宣言的原则要求。

二、方法

(一)手术方法

对照组患者采用传统手术方式，试验组患者采用改良手术方式。

1．传统手术方式

传统手术方式包括改良Brisson术、Borsellino术、带蒂岛状包皮瓣转移术矫正隐匿阴茎等。

2．改良手术方式(图1)

患儿取平卧位气管插管全身麻醉，消毒铺巾后开始手术。第1步：取背侧阴茎耻骨角点为起点(A点),通过牵拉阴茎明确阴茎体长度(确定B点)；完全松解包茎及包皮粘连后，测量阴茎头最大横径，以此确定阴茎体周长[周长＝(龟头最大横径+2 mm)×π],根据阴茎体周长一半确定腹侧保留皮肤的起点(C点)；连接AB、BC，分别做与之相交的平行线，交叉点确定为D点，构成矩形皮瓣。同样方法确定对侧D’点。第2步：沿腹侧正中线切开阴茎皮肤及皮下组织至阴茎阴囊交界处并切开包皮狭窄环。第3步：充分暴露阴茎头，检查尿道口有无异常。第4步：于阴茎头偏背侧以prolene线做牵引，在距离冠状沟2~3 mm处平行冠状沟环形切开包皮内板后进行阴茎皮肤脱套至阴茎根部，同时切除筋膜异常附着的纤维索带及部分阴茎悬韧带。第5步：用prolene线将阴茎背侧12点位置阴茎悬韧带上方白膜缝合固定于A点下方组织重建阴茎耻骨角，注意避免损伤阴茎血管神经束。第6步：分别向D点和D’点方向裁减阴茎阴囊交界区皮肤，借用部分阴囊皮肤(以C点可无张力上提至冠状沟区6点位置为宜)。第7步：以prolene线将D点和D’点外侧深面致密筋膜(松弛状态下，距离取1/2阴茎头宽度)固定于阴茎4点、8点位置白膜处，缝合D点和D’点后重建阴茎阴囊角。第8步：缝合筋膜层重新分布筋膜层张力。第9步：裁减缝合剩余的阴茎腹侧皮肤及包皮内外板切口，完成手术。

(二)术后处理

术后采用常规阴茎垂直腹壁套袖式方法包扎，术后第3天拆除外层弹力绷带，术后第7天开始浓盐水(50 g食盐+4 000 ml温水)坐浴1周(每天3次，每次10 min)，术后第1、3、6、12个月门诊随访。

(三)术后评估

术后统计分析各组患儿皮瓣缺血、水肿、皮肤裂开等近期并发症情况。

术后6个月进行远期评估。(1)按照Boemers评价标准对术后阴茎外观做评价，该标准分为以下3个等级：①良好，阴茎体显露及阴茎体皮肤覆盖良好，无显著瘢痕；②一般，阴茎体显露有所改善，有或无阴茎体皮肤臃肿，阴茎体显露良好伴有阴茎体皮肤臃肿；③不良，阴茎体显露不良，不论阴茎体皮肤覆盖良好与否。(2)采用温哥华瘢痕量表(Vancouver scar scale，VSS)对术后手术区域瘢痕增生情况进行评定，VSS评分<5分为轻度瘢痕增生，VSS评分5~<10分为中度瘢痕增生，VSS评分≥10分为重度瘢痕增生。(3)依据塔形、圆柱形、倒塔形分类，对各组进行整体外形评估[4,5,6]。

三、统计学处理

采用SPSS 24.0统计学软件进行数据分析。计数资料以例(%)表示，采用卡方检验进行分析。P<0.05为差异有统计学意义。

结　果

一、一般资料

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